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■ On  tumours  Of  the  bl 


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ON 


TUMOURS  or  THE  BLADDER 


BY     THE     SAME    AUTHOR. 

STUDENT'S  CHEA.P  EDITIONS. 

Clinical  Lectures  on  Diseases  of  tlie  Urinary  Organs 

Delivered  at  University  College  Hospital.    Seventh  Edition,  8vo.  2«.  6d. 

Lectures  on  some   Important  Points  in  coanection  with  the 
Surgery  of  the  Urinary  Organs.    8vo.  2^.  ed. 

The  Diseases  of  the  Prostate  :  their  Pathology  and  Treatment ; 

Co'mprising  the  Jacksonian  Prize  Essay  for  1860.    Eifth  Edition,  8vo.  2.s.  Gd, 


The  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Pistulae. 

The  Jacksonian  Prize  Essay  for  1852.    Third  Edition,  870. 10s. 

Practical  Lithotomy  and  Lithotrity ; 

Or,  an  Inquiry  into  the  best  Modes  of  Removing  Stone  from  the  E'adder. 
Third  Edition,  8vo.  10s. 

The  Preventive  Treatment  of  Calculous  Disease,  and  the  Use  of 
Solvent  Remedies. 

Second  Edition,  fcp.  8vo.  2s.  Gd, 


^  / 


ON  ^ 

TUMOURS  OF  THE  BLADDER 

THEIE 

NATURE,  SYMPTOMS,  AND  SURGICAL  TREATMENT 


PEECEDED    BY 


A   CONSIDERATION  OF   THE   BEST   METHODS 

OF    DIAaNOSING  ALL   FOEMS   OF   VESICAL   DISEASE,  INCLUDING 

DIGITAL    EXPLORATION    AND    ITS    RESULTS 


[ii\   vLTxmttaxi^   lUttstratioits 


BY 

Sir  HENEY  THOMPSON,  RE.C.S.,  M.B.Lond. 

SURGEON  EXTBAORDDTAKY  TO  H.  M.  THE  KING  OP  THE  BELGIANS 

PROFESSOR  OF  SURGERY  AND  PATHOLOGY  TO  THE  ROYAL  COLLEGE  OF  SURGEONS 

CONSULTING  SURGEON  TO  UNIVERSITY  COLLEGE  HOSPITAL,  ETC. 


PHILADELPHIA 
BLAKISTON,     SON,     &     CO. 

1012    WALNUT    STREET 
1884 


PEEFACE, 


A  CONSIDEEABLE  PORTION  of  this  work  is  formed 
by  the  matter  of  two  lectures  given  by  me  at  the 
Royal  College  of  Surgeons  in  June  of  the  present 
year.  Of  these  lectures  the  medical  journals  pre- 
sented condensed  reports,  embracing  about  one-half 
of  the  original  composition. 

I  now  present  the  lectures  entire,  although  not 
preserving  the  exact  form  in  which  they  were 
delivered,  since  numerous  additions  were  rendered 
necessary,  in  order  to  elucidate  the  subject  treated 
of  more  fully  than  it  is  possible  to  do  in  the  narrow 
limits  allotted  to  oral  communications.  Besides 
these,  I  have  appended  notes,  histories,  tables  of 
cases,  etc.,  as  well  as  many  illustrations  from  micro- 
scopic and  other  specimens  exhibited  by  me  in  the 
College  Theatre. 

London  :  35  Wimpole  Stkbet,  W. 
July  1884. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/ontumoursofbladdOOthom 


CONTENTS. 


■HAPTER  PAGE 

I.     DIAGNOSIS 1 

n.     DIGITAL   EXPLOEATION   OF   THE    BLADDER.  .       17 

IIL  TUMOURS  OF  THE  BLADDER:  THEIR  PHYSICAL 
CHARACTERS  AND  INTIMATE  STRUCTURE. 
SYMPTOMS   AND   SIGNS  OF   THEIR   PRESENCE       39 

IV.     OPERATIONS     FOR    THE    REMOVAL     OF    TUMOUR, 

AND   THEIR   RESULTS:    CASES   AND  TABLE     ,       71 


LIST    OF   PLATES. 


fLATK 

I.    Section  of  Healthy  Mucous  Membrane,  made 

DIEECTLY  AFTER  DEATH,  FROM  THE  APE  :  SHOW- 
ING Natural  Folding  of  the  Membrane  in 
THE  emptied  Condition  of  the  Bladder, 
and  the  resemblance  the  Fold  bears  to  a 
Papilla:    x  160 To  face  p.  h^ 

II.  Fimbriated  Papilloma,  showing  two  of  the 
slender  Papillomatous  Processes  or,  so 
called,  '  Villi  ' :  x  160.  (From  Case  15  of 
the  Table) „  59 

III.  Fibro-Papilloma  :  under  a  Low  Power  (  x  80) 

to  show  general  Arrangement  of  Struc- 
ture.   (From  Case  No.  4  op  the  Table)      .  „  60 

IV.  Fibro-Papilloma  :  under  High  Power  (  x  340), 

showing  a  Capillary  Vessel  and  a  few 
Non-striped  Muscle-Fibres.  (From  Case 
No.  4  OF  the  Table) „  60 

V.  Example  of  the  '  Transitional  '  Type  op 
Tumour  :  showing  the  Ground-Substance 
infiltrated  with  variously-shaped  Cells; 

AND     numerous     BLOOD- VESSELS    RUNNING    TO 

the  Surface  :  one  has  given  way,  and 
EFFUSED  Blood  is  well  shown  at  the 
highest  point  :  x  160.  (From  Case  No.  12 
of  the  Table) „  61 

VI.  Epithelioma  :  showing  Ingrowth  of  Epithe- 
lium AND  A  '  Nest  '  in  the  Centre  op  the 
Section  :  x  160.  (From  Case  No.  6  of  the 
Table) „  62 


TUMOUES  OF  THE  BLADDER. 


CHAPTER   L 

DIAGNOSIS. 

Necessity  for  systematic  inquiry  into  and  observation  of  symptoms — • 
Scheme  for  examining  them — Physical  examinations — Relief  of 
obscure  and  painful  symptoms — A  case — Tactile  examination  of 
interior  of  bladder — A  case  resulting  in  removal  of  vesical  tumour 
— Considerations  as  to  the  best  means  of  accomplishing  it. 

It  is  a  fact  which  now  begins  to  appear  somewhat 
surprising,  that,  until  a  very  recent  period,  the  subject 
of  tumours  of  the  bladder  has  received  a  compara- 
tively small  share  of  attention,  either  from  patholo- 
gists or  from  practical  surgeons.  The  former  have 
noticed  these  morbid  products,  chiefly  to  remark  on 
their  rarity  ;  the  latter  have  alluded  to  them  chiefly, 
as,  for  the  most  part,  beyond  the  power  of  art  to  re- 
move. Yet  there  is  little  doubt  that  these  growths 
are  by  no  means  uncommon,  and  recent  experience 
is  teaching  us  that  surgical  treatment  may  often 
greatly  palliate,  and  sometimes  successfully  extirpate, 
the  disease. 


2  ON  TUMOURS  OF  THE  BLADDER 

It  must  be  admitted  that  these  cases  are  almost 
invariably  somewhat  difficult  to  identify,  especially  in 
an  early  stage.  Hence  the  reason  why  so  little  in- 
formation has  hitherto  been  acquired  respecting  them. 
But  of  late  years,  keener  observation  and  analysis 
of  the  signs  and  symptoms  of  disease  have  led  to  the 
discovery  of  various  morbid  conditions  not  before 
suspected  to  exist ;  and  it  is  owing  to  this  fact  that 
the  presence  of  tumours  in  the  bladder  has  been 
verified,  and  that  the  frequency  of  their  occurrence 
has  been  demonstrated. 

Before  commencing  a  study  of  the  various  pro- 
ducts which  are  grouped  under  the  title  of  tumour, 
I  shall  consider  the  important  preliminary  inquiry  of 
how  best  to  ascertain  their  presence  in  the  bladder, 
and  separate  the  signs  and  symptoms  proper  to  them 
from  those  of  other  affections,  whether  obvious  and 
simple,  or  unusual  and  obscure. 

In  all  cases  of  disease,  whatever  its  seat  or  nature, 
our  first  object  in  examining  a  patient  is  to  form  a 
diagnosis  of  his  disease  by  investigating  its  pheno- 
mena. The  account  which  he  gives  of  his  sensations 
is  critically  received  and  noted  ;  the  physical  signs 
which  relate  to  the  performance  of  function,  as  well 
as  those  which  denote  some  change  in  form  and 
structure,  are  observed,  and  the  secretions  are  chemi- 
cally and  microscopically  examined. 

These    data    being    obtained,    the    diagnosis    is 


DIAGNOSIS  6 

generally  clear.  If  it  is  not  so,  the  defect  is  rarely  due 
to  our  want  of  scientific  knowledge  of  disease,  but  to 
our  inability  to  obtain  the  facts  required  in  the  par- 
ticular case.  Thus  the  diagnosis  of  heart  and  lung 
diseases  was  very  obscure,  although  their  pathology 
was  well  understood,  until  the  practice  of  auscultation 
and  percussion  revealed  facts  which  had  not  been 
hitherto  attainable  during  life.  Hence  it  is  now 
rare  to  meet  with  serious  disease  of  those  organs 
which,  after  adequate  examination,  can  be  termed 
obscure. 

But  in  affections  of  the  kidney  and  bladder, 
accessible  as  these  organs  are  to  inquiry,  the  one  by 
sounding,  the  other  through  its  secretion,  it  is  still  by 
no  means  uncommon  to  meet  with  a  group  of  symp- 
toms indicating  serious  disease,  of  which  the  diagnosis 
is  by  no  means  clear.  The  disease  shall  have  existed 
for  months,  or  even  for  years  ;  careful  examinations 
shall  have  been  made  by  several  observers,  and  yet, 
not  only  shall  there  be  no  agreement  among  them 
as  to  the  nature  of  the  affection,  but  differences  of 
opinion  may  exist  as  to  its  locality  ;  for  example,  as 
to  whether  the  bladder  or  the  kidney  is  the  chief  seat 
of  the  malady. 

These  obscure  diseases,  as  already  intimated,  are 
for  the  most  part  chronic  in  their  character.  There 
is  rarely  any  question  of  obscurity  when  dealing  with 
acute  disease,  since  the  local  pain  and  other  signs,  as 

B  2 


4  ON  TUMOURS  OF  THE  BLADDER 

well  as  the  condition  of  the  urine,  mostly  suffice  to 
indicate  the  organ  which  is  aiFected. 

It  is  for  the  purpose  of  facilitating  the  study  of 
our  subject,  that  I  shall  now  endeavour  to  sketch, 
more  fully  than  I  have  elsewhere  hitherto  done,  a 
systematic  mode  of  inquiry  respecting  those  derange- 
ments of  the  urinary  function  which  are  to  be 
regarded  either  as  signs  or  symptoms  of  disease 
affecting  any  part,  at  least,  of  the  bladder  and  ure- 
thra. My  object  is  to  enable  the  student  to  arrive, 
by  the  shortest  route,  first,  at  the  true  facts  of  the 
case  ;  and,  secondly,  at  the  conclusions  which  those 
facts  warrant. 

In  pursuance  of  this  plan,  let  me  premise  that 
the  male  sex  of  the  patient  is  always  to  be  under- 
stood ;  modifications  which  are  obvious  and  therefore 
not  specified  being  requisite  in  cases  of  the  other 
sex. 

The  first  fact  to  be  regarded  in  commencing  an 
investigation  relative  to  any  morbid  condition  aficct- 
ing  the  urinary  organs  is,  that,  with  very  rare  excep- 
tion, the  act  of  micturition  is  always  -more  frequent 
than  natural.  But  it  is  particularly  important  to 
note  whether  that  frequency  is  manifested  more  by 
night  or  by  day,  during  rest  of  the  body,  or  during 
movement,  or  any  other  circumstance  which  may  thus 
afi'ect  the  function. 

Secondly^  we  are  next  to  inquire  whether  pain  is 


DIAGNOSIS  5 

felt  ill  micturition,  and  if  so,  whether  before,  during, 
or  after  the  act  ;  what  is  its  character — acutely  smart- 
ing, evanescent,  dull,  or  continuous  •  also,  what  is 
the  precise  seat  of  the  pain — in  the  penis,  above  the 
pubes,  or  elsewhere. 

Thirdly^  has  hlood  been  seen  in  the  urine  ?  is  it 
brownish  and  intimately  mixed,  or  not  mixed,  and  of 
a  bright  red  colour  ?  Has  the  stream  been  observed 
to  commence  with  urine  apparently  normal,  or  with 
only  a  faint  red  tint,  and  to  end  in  deep  red,  evidently 
charged  with  blood.  Is  the  blood  augmented  by,  or 
does  it  occur  after,  exercise? 

Fourthly^  the  character  of  the  stream  is  to  be 
observed,  whether  it  is  small  or  full,  irregular  in 
form,  feeble  or  forcible,  continuous  or  the  reverse, 
issuing  in  part  or  wholly  by  fistulous  channels. 

Fifthly^  is  the  urine  cdtered  in  appearance  from 
the  healthy  standard,  or,  as  observed  by  precise  tests, 
in  its  physical  or  chemical  qualities  ?  It  is  import- 
ant to  observe  whether  the  first  issue  of  the  stream 
contains,  or  is  preceded  by,  an  obviously  muco-puru- 
lent  discharge.  Is  the  amount  of  urine  passed  large 
or  small  in  quantity  ?  Are  the  normal  constituents 
large  or  the  reverse?  or  are  any  unnatural  elements 
present,  as  albumen,  sugar,  &c.  ?  What  morganic 
deposits,  crystalline  or  other,  are  met  with,  and  what 
organic  materials  are  found  as  regular  or  occasional 
deposits  in  the  urine  ? — leading  to  the  whole  subject 


6  ON  TUMOURS  or  THE  BLADDER 

of  urine  analysis,  whicli  it  cannot  be  necessary  to 
pursue  further  in  this  place.  ^ 

Sixthly,  inquiry  must  be  made  for  the  presence 
of  pain  in  the  back,  loins,  and  hips,  past  or  present, 
permanent  or  transitory,  and  for  the  occurrence  of 
periodical  attacks,  obviously  renal. 

Lastly,  signs  of  dropsy  and  other  complications  of 
imperfect  renal  function  must  be  sought. 

The  prosecution  of  these  inquiries,  and  especially 
made  in  this  order,  decides  for  a  great  number  of 
cases  the  condition  of  the  patient,  but  it  will  not  do 
so  in  all.  Physical  exammation  is  in  some  cases  ne- 
cessary :  it  is  so  when  the  stream  of  urme  is  habi- 
tually small,  when  micturition  is  frequent,  painful, 
and  difficult,  when  also  it  is  feeble  in  elderly  men  ;  if 
obstruction  is  manifest  in  any  case,  if  the  urine  be 
persistently  alkaline  and  muco-purulent,  if  red  blood 
is  passed  in  the  urine,  and  especially  if  symptoms  of 
irritated  bladder  are  also  present. 

The  steps  of  physical  diagnosis  are  very  simple, 
easy  of  performance,  and,  although  often  much 
dreaded  by  the  patient,  entail  only  a  moderate  degree 
of  pain  when  properly  executed,  and  rarely  any  risk 
of  exciting  febrile  or  other  disturbance  if  they  are 
employed  under  certain  conditions,  e.g.  with  exceeding 
gentleness,  not  during  the  presence  of  local  inflam- 

'  See  Clinical  Lectures,  by  the  Author,  Lect.  XXIV.     7th  edition. 
London  :  Churchill,  1883. 


DIAGNOSIS  7 

mation,   and    with    due   precautions  for  the   patient 
afterwards. 

Adequate  patency  of  the  urethra  is  determined  by 
passing  a  soft  bougie  of  moderate  size  ;  ability  of  the 
bladder  to  empty  itself  by  the  natural  efforts  by  pass- 
ing a  flexible  catheter  immediately  after  the  act  of 
micturition  ;  the  presence  of  a  foreign  body  by  intro- 
ducing a  small  beaked  sound  and  prosecuting  the 
search  in  a  systematic  but  delicate  and  gentle  manner. 
The  condition  of  the  prostate  and  base  of  the  bladder 
is  ascertained  by  rectal  examination  with  the  finger, 
searching  there  for  hypertrophy,  cancerous  deposit, 
and  for  calculus  in  exceptional  circumstances,  such 
as  impaction,  irregular  situation,  unusual  size,  &c. 
Examination  of  the  perineum  and  scrotum,  as  well  as 
palpation  and  percussion  of  abdomen  in  the  supra- 
pubic region,  and  in  both  renal  regions,  in  the  line  of 
the  ureters,  for  retained  urine,  tumour,  enlargement, 
fluctuation,  points  of  tenderness,  &c. 

The  outline  of  an  exhaustive  scheme  of  research 
has  thus  been  presented  ;  one  which  suffices  for  the 
solution  of  a  very  large  proportion  of  all  the  cases 
which  occur  in  practice.  I  think  it  may  be  fairly 
said  to  be  adequate  to  the  solution  of  ninety- nine  out 
of  one  hundred,  so  far  as  a  rough  numerical  estimate 
be  possible. 

But  it  follows  that  the  most  patient  application  of 
the  inquiry  described   sometimes  fails  to  reveal  the 


8  ON  TUMOUES  OF  THE  BLADDER 

cause  of  symptoms  ;  although  it  may,  and  often  does, 
arouse  suspicions  as  to  what  that  cause  may  be. 
Thus,  the  evidence  available  in  an  exceptionally 
obscure  case  may  point  in  the  direction  of  impacted 
calculus,  which  is  associated  usually  with  extremely 
painful  and  frequent  micturition,  and  muco-purulent 
or  occasionally  blood-stained  urine  ;  or  may  indicate 
the  presence  of  a  growth  within  the  bladder  (not  can- 
cerous deposit  in  its  walls,  which  is  readily  recognised 
from  the  rectum),  such  growth  being  usually  asso- 
ciated with  loDg-continued  or  repeated  bleeding,  and 
sooner  or  later  depositing  in  the  urine  organic  debris, 
the  structure  of  which  may  determine  its  character. 
In  either  case  no  permanent  relief  is  attainable  with- 
out operation. 

Besides  the  conditions  named,  there  may  be,  as  in 
the  cases  of  elderly  men  who  are  unable  to  pass  any 
urine  without  very  frequent  catheterism,  another 
cause,  not  very  infrequent,  of  the  most  distressing 
cystitis  ;  one  that  is  rarely  amenable  to  relief  by 
ordinary  treatment,  because  the  cystitis  itself  is  main- 
tained by  the  very  agency,  the  catheter,  without 
which  the  patient's  existence  is  impossible.  A  vicious 
circle  of  actions  is  thus  set  going,  which  can  only 
move  from  bad  to  worse.  In  all  the  conditions 
described  the  patient's  fate  is  sealed  ;  but  even  this 
grave  fact  does  not  disclose  all  the  severity  of  his 
lot ;  since  it  is  almost  inevitable  that  the  fatal  event 


DIAGNOSIS  9 

must  arrive  through  severe  and  protracted  suffering. 
The  painful  experience  which  I  have  necessarily  had 
of  so  much  misery  of  this  kind,  and  for  which,  in  the 
later  stages  of  disease,  little  relief  is  afforded  except 
through  the  influence  of  narcotics,  has  long  impressed 
me  strongly  with  the  desire  and  the  hope  of  finding 
the  means  of  escape  for  some  of  these  patients, 
equally  from  the  fatal  issue  and  from  the  suffering 
which  precedes  it. 

Fifteen  years  ago  (January,  1869),  for  a  man 
about  60  years  of  age,  in  University  College  Hospital, 
I  first  opened  a  bladder  with  the  sole  view  of  afford- 
ing relief  in  a  case  of  painful  cystitis  of  the  kind 
described,  no  crisis  of  retention  being  present  ;  by 
making  a  suprapubic  opening  and  maintaining  a 
tube  there  during  some  weeks,  in  order  to  drain  and 
relieve  the  bladder.  I  repeated  this  proceeding  in 
six  other  cases,  affording  some  relief,  but  with  less 
of  permanent  benefit  to  patients  than  I  had  hoped 
to  attain.  The  opening  was  ill-placed  for  drainage 
purposes  ;  it  became  very  sore  from  contact  with 
urine,  and  kept  the  patient  for  the  most  part  confined 
to  his  room.  But  the  last  case  in  which  I  did  this 
operation  was  so  remarkable,  and  impressed  me  so 
strongly,  that  from  that  time  I  determined  on  a 
different  course  for  the  future  ;  and  this  at  length 
issued  in  the  plan  which  I  have  now  put  in  practice 
nearly  four  years,  and  the  results  of  which  I  shall  lay 


10         ON  TUMOUES  OF  THE  BLADDER 

before  you  without  any  reserve  to-day.  But  first,  I 
shall  ask  you  to  listen  to  a  very  brief  report  of  the 
case  just  referred  to. 

Mr.  C.  was  aged  31  when  first  seen  by  me  in  1870. 
During  the  previous  six  years  has  had  occasional  attacks  of 
bleeding.  The  urine  always  more  bloody  at  the  end  of  the 
stream  than  at  the  beginning.  The  vesical  origin  of  the 
blood  was  on  this  ground  suspected  at  that  time. 

After  two  or  three  visits,  he  took  a  sea  voyage  for  hirf 
health,  and  thought  himself  cured.  But  he  came  again  in 
October  1874,  having  had  several  fresh  attacks  recently.  I 
sounded  him,  and  felt  nothing  ;  some  fusiform  cells  were 
observed  in  the  urine,  and  are  sketched  in  the  note-book  at 
that  visit. 

1876.  Has  continued  to  bleed,  and  more  frequently. 
Found  three  ounces  of  residual  urine,  and  advised  use  of 
catheter  daily ;  which  was  found  to  check  bleeding,  as  when 
there  was  no  straining  there  was  no  blood. 

1877.  Passes  shreds  of  organic  tissue  ;  sounded,  nothing 
felt ;  weaker  ;  micturition  frequent  and  painful. 

1878.  Sufferings  so  great  in  micturition  that  I  resolved 
to  make  a  suprapubic  opening  into  the  bladder  to  rest  and 
drain  it,  and  enable  him  to  obtain  some  sleep,  which  has 
been  terribly  broken  by  constant  straining.  The  operation 
afforded  some  relief,  but  he  gradually  became  weaker,  and 
sank  about  a  month  afterwards. 

At  the  autopsy  a  single  pedunculated  tumour  was  found 
in  the  bladder  ;  it  resembled  in  form  and  size  an  ordinary 
fig.  It  could  have  been  easily  removed  had  the  suprapubic 
opening  been  enlarged  (see  fig.  1). 

It  was  clear  to  me  from  this  case  that  the  ordinary 
sound,  '  a  lengthened  finger '  in  practised  hands,  as  I 
had  often  and  truly  termed  it  to  my  class,  had  proved 


DIAGNOSIS  11 

incapable  of  giving  me  sufficient  information  relative 
to  the  presence  of  a  considerable  growth  within  the 


JplQ,  1. — Fimbriated  Papilloma,  with  narrow  peduncle.     From  case 
of  Clark,  xt.  38.     (Museum  of  University  College,  No.  ],.500.) 

bladder.  Supposing  that  I  could  but  once  have  put 
my  real  finger  there,  instantly  discovering,  as  I 
should  have  done,  that  easily  removable  tumour  : 
how  different  would  have  been  the  issue  of  that 
unhappy  case  !  He  might  have  been  enjoying  life 
and  health  to-day.  What  then  was  to  prevent  me 
in  future,  under  circumstances  of  equal  gravity  and 
like  obscurity,  from  determining  the  presence  or 
absence  of  such  a  growth,  by  the  direct  sense  of  touch, 
as  I  could  so  easily  have  done  there,  had  the  necessity 
for  applying  it  ever  occurred  to  me  ?  The  questions 
therefore  naturally  presented  were  :  Might  it  not  be 
possible  to  examine  with  my  finger  the  whole  in- 
terior  surface  of  the  bladder  ;  and,  if  so,  from  what 
region  could  such  exploration  be  most  easily  and 
safely  accomplished — from  the  perineum,  or  from 
above  the  pubes  ?  After  experiment  on  the  dead 
body  the  answer  seemed  not  doubtful.     With  a  small 


12         ON  TUMOUKS  OF  THE  BLADDER 

opening  into  the  membranous  urethra  from  the 
perineum,  just  large  enough  to  admit  the  finger 
to  arrive  at  the  neck  of  the  bladder,  and  making 
at  the  same  time  firm  suprapubic  pressure,  I  could 
explore  without  difiiculty  every  portion  of  the  surface 
described.  If  then  by  means  of  anaesthesia  I  could 
attain  that  degree  of  fiaccidity  and  inertia  in  the 
living  body  which  is  natural  to  the  dead  subject, 
why  should  I  not  be  able  to  effect  as  easily  the 
exploration  in  the  former  case  as  in  the  latter  ? 

Opportunity  for  making  the  experiment  soon 
occurred,  partly  in  the  course  of  a  lithotomy  case  or 
two  ;  and  finally  in  the  person  of  a  patient  who  came 
under  my  care  in  1880,  with  severe  and  obscure 
symptoms.  At  the  outset  of  this  case  I  met  with  a 
small  calculus  and  crushed  it,  but  subsequently  found 
another,  as  I  thought,  impacted,  not  being  able  to  re- 
move it  by  the  lithotrite.  It  was  with  the  object  of 
ascertaining  the  real  state  of  the  case  that  I  decided 
thus  to  explore  the  bladder,  and  did  so  in  November 
of  that  year.  I  invited  Dr.  Seegen,  of  Vienna,  and 
Dr.  Paggi,  of  Florence,  who  happened  to  be  in  town, 
as  well  as  Mr.  Ceely,  of  Aylesbury,  to  be  present. 
Having  made  the  median  incisions,  and  complete 
fiaccidity  of  the  abdominal  muscles  having  been 
attained  by  the  influence  of  ether,  I  felt  as  soon  as  the 
finger  entered  the  bladder  that  there  was  no  difiiculty 
in  exploring  the  whole  interior,  and  soon  detected  the 


DIAGNOSIS  13 

presence,  not  of  a  stone,  but,  to  my  surprise,  of  a  single 
pedunculated  tumour  of  considerable  size,  with  a 
thick  coating  of  phosphates  deposited  on  the  surface. 
It  had  been  this  coating,  together  with  the  immobility 
of  the  mass  as  previously  determined  by  a  lithotrite, 
which  had  suggested  to  me  the  presence  of  impacted 
calculus.  I  seized  the  tumour  with  a  small  lithotomy 
forceps  and  twisted  it  off  at  the  neck.  The  patient, 
contrary  to  my  expectations,  made  a  rapid  recovery; 
had  no  return  of  the  growth  or  any  sign  thereof,  and 
has  enjoyed  excellent  health  and  activity  ever  since, 
as  he  does  at  this  day.  That  operation  took  place  in 
the  autumn  of  1880,  now  nearly  four  years  ago.  I 
waited  a  year  and  a  half  before  presenting  this  man 
and  his  history  to  the  fellows  of  the  Royal  Medical 
and  Chirurgical  Society,  and  before  proposing  also 
to  make  his  case  a  precedent  to  be  followed  system- 
atically in  obscure  cases  for  the  future,  having  at 
this  second  date  adopted  the  operation  in  three  other 
cases  of  chronic  bladder  disease,  which,  however, 
were  not  examples  of  tumour  in  any  form.  The 
case,  with  diagram  of  the  growth  removed,  forms 
No.  1  in  the  Table  of  Cases  at  the  end  of  this 
volume. 

I  then  determined  to  regard  the  systematic  exa- 
mination of  the  bladder  by  means  of  the  finger  as  a 
desirable,  and  indeed  as  a  necessary,  proceeding  in 
obscure  disease  believed  to  affect  the  bladder,  when 


14         ON  TUMOURS  OF  THE  BLADDER 

other  means,  including  careful  sounding  under  ether, 
had  failed  to  detect  the  cause.  And  in  order  to 
distinguish  the  new  method,  I  termed  it  '  Digital 
Exploration  of  the  Bladder,'  and  under  this  name  I 
made  the  first  published  account  of  it,  not  in  this 
country,  but  in  La  Semaine  Medicale  of  Paris,  in 
June  18,  1882;  specifying  also  the  cases  in  which  it 
might  be  deemed  applicable. 

In  the  surgical  proceeding  itself  there  is  nothing 
new,  nor  did  it  ever  occur  to  me  that  it  could  be 
claimed  in  that  sense  by  any  modern  surgeon.  Like 
others  I  had  often  opened  the  urethra  from  the  peri- 
neum for  stricture,  for  chronic  and  obstinate  urinary 
fistulte,  for  impacted  calculus,  for  calculus  sacculated 
m  front  of  the  neck  of  the  bladder,  and  once  after 
lithotrity  when  the  patient  could  pass  no  urine  except 
by  catheter,  and  was  unable  to  introduce  the  instru- 
ment, &c.  But  the  object  with  which  I  have  recently 
proposed  to  operate  is  a  new  one,  inasmuch  as  it  is 
solely  the  exj^loration  of  every  part  of  the  bladder 
with  the  end  of  the  fino;er,  in  order  to  diag-nose  its 
condition,  and  not  by  any  means  necessarily  to  per- 
form any  further  operation,  unless  indeed  this  should 
turn  out  to  be  required  by  the  discovery  of  a  tumour 
or  other  condition  admitting  of  surgical  treatment. 
To  effect  this  purpose,  then,  it  was  extremely  impor- 
tant to  determine  what  is  the  shortest  and  easiest 
route  for  the  surgeon,  and  at  the  same  time  by  what 


DIAGNOSIS  15 

method    would  the  smallest  amount    of  risk  to  the 
patient  be  incurred. 

At  first  sight  it  appeared  that  an  incision  involv- 
ing the  neck  of  the  bladder  must  be  necessary,  and 
that  the  operation  must  therefore  be  some  form  of 
cystotomy.  Happily  experiment  proved  that  no  such 
extended  incision  would  be  required,  and  that  a  section 
carried  from  the  perineum  to  the  urethra,  in  other 
words  ^  external  urethrotomy,'  would  suffice  for  my 
purpose.^  Now,  this  is  a  procedure  almost  without 
risk.  The  mere  section  of  parts  from  the  perineal 
surface  in  the  median  line,  down  to  any  part  of  the 
urethra  anterior  to  the  23rostate  is  one  of  the  simplest 
and  least  dangerous  of  surgical  operations.  If  in 
addition  to  the  section,  the  prostatic  urethra  together 
with  the  wound  have  to  form  a  route  for  the  repeated 
introduction  of  instruments,  and  for  the  removal  of 
a  tumour,  the  risk  is  increased  in  proportion  to  the 
amount  of  work  to  be  done  ;  but  even  then  the  fresh 
danger  incurred  does  not  arise  from  the  urethral 
lesion  so  much  as  from  the  process  of  detaching  the 
growth  from  the  walls  of  the  bladder. 

^  It  fell  to  my  lot  to  write  a  brief  history  of  that  operation  for  my 
earliest  Jacksonian  prize  essay  in  1851,  and  I  recorded  there  that  it 
was  practised  in  the  end  of  the  seventeenth  century  by  Richard  Wise- 
man in  this  country,  and  that  at  about  the  same  period,  and  subse- 
quently, it  was  known  and  practised  in  France,  under  the  name  of  the 
'  boutonniere,'  by  Tolet,  Colot,  Petit,  Ledran,  and  others.  By  all 
these  it  had  been  adopted  to  give  an  outlet  to  retained  urine,  and 
to  relieve  impassable  stricture.  My  purj^ose,  however,  was  wholly 
different,  as  is  seen  above. 


16         ON  TUMOURS  OF  THE  BLADDER 

In  lithotomy  the  urethral  route,  and  particularly 
the  neck  of  the  bladder,  are  injured  by  forcible  ex- 
traction of  a  large  and  rough  calculus,  but  nothing 
analogous  to  that  dangerous  process  occurs  in  the 
removal  of  tumour. 

Old,  however,  as  is  the  surgical  proceeding  in 
question,  whether  in  modern  language  it  be  termed 
'  external  urethrotomy,'  or,  as  with  the  older  French 
surgeons,  the  quaint  term  of  the  '  boutonniere  '  be 
adopted  (the  term  itself  shows  how  very  simple 
even  at  that  period  they  considered  it),  the  mode  of 
performing  it  appears  to  me,  after  a  considerable 
experience,  not  altogether  a  matter  of  indifference. 
I  shall  in  the  first  place,  however,  premise  that  there 
is  no  longer  any  doubt  that  the  median  incision  of  the 
perineum  opens  a  shorter  road  to  the  neck  of  the 
bladder  than  an  incision  commenced  from  any  lateral 
part  of  that  region,  although  the  question  has  been 
raised.  Considering  this  point  to  be  determined,  I 
shall  describe  in  the  succeeding  chapter  the  steps 
of  the  proceeding  which  appear  to  me  the  most  de- 
sirable to  be  followed  in  order  to  attain  the  end 
proposed  with  ease  and  safety. 


DIGITAL    EXPLORATION    OF    THE    BLADDER  17 


CHAPTER   11. 

DIGITAL    EXPLORATION    OF    THE   BLADDER. 

Mode  of  performing — Conditions  which  may  be  met  with— Draining 
the  bladder — Exploration  in  women — Results  of  exploration  in 
forty -three  cases  — Brief  reports  of  each. 

The  Operation. — The  position  of  the  patient,  and 
the  general  accessories  necessary,  are  those  require-cl 
for  lithotomy. 

After  ether  has  been  given,  a  median  staff  with  a 
short  curve,  wide  and  deeply  grooved,  is  passed  into 
the  bladder,  and  the  patient  is  brought  down  to  the 
edge  of  the  table,  the  feet  and  hands  are  attached  by 
anklets  and  wristbands  and  held  by  two  assistants  in 
the  usual  manner,  another  holding  the  staff.  The 
surgeon,  being  seated,  introduces  into  the  rectum  his 
left  forefinger,  so  as  to  feel  with  its  tip  the  position  of 
the  grooved  staff,  separated  by  intervening  tissues, 
and  to  verify  the  apex  of  the  prostate,  on  which  he 
may  place  the  point  of  his  finger  as  a  guide.  He  may 
take  the  handle  of  the  staff  with  his  right  hand  and 
place  it  m  the  position  required,  before  returning  it 
to  the  hand  of  the  assistant.     Maintaining  his  left 

c 


18  ON    TUxMOURS    OF    THE    BLADDER 

index  in  the  position  described,  the  operator  then 
makes,  with  a  long,  narrow,  straight -backed  bistoury 
(fig.  2),   a  vertical   incision  through   the    skin  and 


Fig.  2. 


cellular  tissue  in  the  middle  line,  say  in  the  raphe, 
about  an  inch  and  a  quarter  long,  the  lower  extremity 
of  the  incision  terminating  about  three  quarters  of  an 
inch  above  the  anus.  He  next  enters  the  bistoury, 
with  its  cutting  edge  upwards,  in  a  horizontal  direc- 
tion, at  the  lower  part  of  the  incision,  just  above  the 
upper  border  of  the  bowel  and  parallel  with  it,  and, 
guided  partially  by  the  proximity  of  the  left  index 
there,  directs  the  point  inwards  until  it  arrives  at  the 
membranous  part  of  the  urethra,  which  it  penetrates, 
entering  firmly  the  groove  of  the  staiF.  Contact 
being  distinct,  he  incises  the  urethra  on  the  staff  for 
a  few  lines  by  a  backward  and  forward  movement  of 
the  point,  and  then  withdraws  the  bistoury,  cutting 
slightly  perhaps  a  little  of  the  tissues  upwards  as  he 
does  so,  avoiding  as  far  as  possible  any  section  of  the 
bulb  itself,  and  making  room  enough  only  for  the 
finger  to  enter.  He  now  inserts  in  the  groove  of  the 
staff  the  tapering  gorget-like  director  (which  may  be 
itself  grooved  in  order  to  enter  on  the  back  of  the 
knife  which  has  been  employed,  and  before  the  latter 


DIGITAL    EXPLORATION    OF    THE    BLADDER  19 


has  been  removed)    (fig.   3),  and  presses  it  gently 
inwards  along  the   urethra   to  the  bladder,  and  he 


Fig.  3. 

may  at  the  same  time  remove  the  left  index  from 
the  rectum  and  take  the  staff  in  that  hand,  so  as  to 
handle  the  two  instruments  simultaneously.  The 
staff  is  withdrawn,  the  director  maintained  in  place 
by  the  right  hand,  the  left  index  is  slowly  and  gently 
insinuated  along  the  director  through  the  neck  of  the 
bladder,  when  the  director  is  withdrawn.  The  tip  of 
the  exploring  finger  is  now  in  ordinary  circumstances 
felt  free  in  the  cavity  of  the  bladder,  and  not  unfre- 
quently  at  once  comes  into  contact  with  and  recognises 
the  morbid  condition  for  which  the  exploration  was 
undertaken.  Whether  or  no,  the  operator,  maintain- 
ing the  index  in  its  place,  and  firmly  pressing  it  into 
the  cavity  of  the  bladder,  rises  from  his  seat  if  neces- 
sary, and  stands  so  that  by  means  of  his  own  right 
hand  he  can  make  firm  suprapubic  pressure,  and 
bring  the  upper  surface  of  the  bladder  into  contact 
with  the  left  index.     This  is  easily  accomplished  if 

c  2 


20         ON  TUMOURS  OF  THE  BLADDER 

anassthesia  is  complete,  that  is,  renders  the  abdominal 
muscles  quite  inert  and  flaccid.  He  rapidly  ascertains 
the  presence  or  absence  of  tumour ;  if  absent,  he  will  by 
slightly  changing  the  point  of  suprapubic  pressure, 
and  also  as  far  as  he  can,  the  direction  of  the  tip  of 
the  left  index,  carefully  examine  bit  by  bit  the  whole 
internal  surface  of  the  bladder.  He  will  first  be  ac- 
quainted with  the  condition  of  the  mucous  membrane 
lining  the  cavity,  and  observe  whether  it  possesses  the 
smooth  satin-like  surface,  so  characteristic  of  the  vesi- 
cal lining  membrane  in  health,  or  whether  it  is  more 
or  less  roughened  or  velvety  in  places,  for  such  con- 
ditions rarely  aifect  the  entire  area.  He  may  find  on 
the  contrary  an  irregular  surface  elevated  in  places  by 
interlacing  lines  of  fibres,  with  corresponding  depres- 
sions and  interstices,  the  signs  of  hypertrophy  of  the 
muscular  coat ;  while  the  existence  of  inequalities 
in  the  surface  of  any  kind,  such  as  small  papillae,  or 
so-called  '  villi,'  is  at  the  same  time  determined. 

Further  examination  with  the  finger-nail  may 
detach  from  the  walls  some  rough-feeling  material  ; 
and  a  more  or  less  substantial  film  may  be  found,  to 
which  earthy  deposits  adhere,  like  a  false  membrane 
which  may  be  peeled  off^  and  removed.  In  other  cases  a 
complete  scale  of  phosphatic  crust  may  be  encountered, 
rather  closely  attached  to  a  roughened  portion  of 
the  wall,  and  be  separated  from  it  without  difficulty. 
And  sometimes  the  finger  may  discover  a  small  cal- 


DIGITAL    EXPLORATION    OF    THE    BLADDER  21 

cuius  half  exposed,  half  hidden,  occupying  partially, 
or  almost  completely,  a  little  sac,  or  lodged  in  a 
crevice,  as  it  were,  and  merely  protruding  from  be- 
tween two  hypertrophied  folds  or  rugae,  which  hold 
it  in  a  position  where  it  has  perhaps  defied  both  the 
sound  and  the  lithotrite.  All  forms  of  prostatic  out- 
growth are  met  with  ;  their  interference  with  the  vesi- 
cal function  can  be  studied,  in  the  relations  which 
they  hold  as  to  size  and  situation  to  the  neck  of  the 
bladder  ;  some  of  them  being  thus  possibly  rendered 
amenable  in  a  slight  degree  to  surgical  treatment  after 
such  recognition  has  been  made,  as  is  partially  illus- 
trated by  a  case.  No.  41,  at  the  end  of  this  chapter. 

Indeed,  it  is  difficult  to  say  at  present  what  may 
not  be  found,  as  fresh  experiences  have  brought  to 
light  conditions  to  some  extent  not  heretofore  recog- 
nised, of  which  I  have  yet  to  speak.  Hence  there  are 
few  occasions,  I  confess,  which  for  me  have  excited  a 
more  lively  interest,  than  the  moment  at  which  my 
finger  enters  a  bladder,  the  condition  of  which  has 
been  a  theme  of  keen  inquiry  and  speculation,  for 
some  months  or  even  for  years  before. 

Almost  certainly,  at  that  moment  the  cause  is 
revealed,  and  the  practical  surgeon  only  can  under- 
stand, if  I  permit  myself  to  say  how  grateful  is  the 
sense  of  satisfaction  when  it  is  suddenly  discovered 
that  the  event  has  amply  justified  the  procedure,  and 
that  the  cause  of  years  of  suffering  is  judged  after 


22         ON  TUMOURS  OF  THE  BLADDER 

examination  to  be  safely  within  our  power  to  remove. 
I  doubt  whether  the  keenest  hunter  in  quest  of  ad- 
venture, or  most  indefatigable  and  hardy  explorer  of 
an  unknown  continent,  realises,  after  long  and  patient 
toil,  happier  moments  following  success,  than  does 
the  operator,  who,  after  protracted  care  and  research, 
tracks  to  a  hidden  source  the  cause  of  certainly  im- 
pending death,  and  is  able  to  save  the  victim ! 

To  return,  supposing  it  is  at  once  apparent  from 
the  examination  just  described  that  tumour  is  pre- 
sent, the  operator  must  next  deliberately  study  its 
size,  form,  situation,  and  mode  of  attachment  to  the 
bladder.  This  is  an  extremely  important  matter, 
and  will  be  considered,  as  well  as  the  best  mode  of 
removing  the  growth,  in  the  next  chapter. 

On  the  other  hand,  no  growth  having  been  found, 
the  next  steps  of  the  proceeding  will  depend  on  what 
other  morbid  or  irregular  condition  has  been  revealed. 
Supposing  that  either  some  calculus  or  other  matter 
has  been  removed,  or  that  the  bladder  and  urethra  are 
to  be  maintained  in  a  state  of  rest  in  order  completely 
to  suspend  their  functions  for  a  few  days,  free  exit  for 
the  urine  must  be  secured.  For  this  purpose  a  soft  but 
stout  indiarubber  tube,  with  a  clear  calibre  of  a  fourth 
of  an  inch,  having  a  lateral  as  well  as  a  terminal 
opening,  and  about  six  inches  long,  is  to  be  fastened 
with  one  end  (smoothly  bevelled)  just  within  the 
bladder,   the  remainder  occupying  the  wound,   and 


DIGITAL    EXPLORATION    OF    THE    BLADDER  23 

protruding  so  as  to  convey  the  urine  direct  to  some 
vessel  suitable  to  receive  it.  If  the  object  of  treat- 
ment is  that  last  described,  the  tube  should  remain 
a  week  or  so,  unless  its  presence  occasions  pain,  in 
which  case  a  soft  large  catheter  may  be  tried  ;  or,  as 
sometimes  happens,  it  is  better  after  the  first  or  second 
day  to  dispense  with  any  instrument,  and  allow  the 
urine  to  take  its  course  through  the  wound.  If,  how- 
ever, the  tube  produces  little  or  no  irritation,  it  should 
remain  several  days,  until  the  bladder  has  been  rested 
and  drained,  say  at  least  for  a  week  ;  even  a  longer 
period  is  sometimes  advantageous  ;  see  Cases  5,  8 
and  43.  The  relief  from  frequent  habitual  cathe- 
terism  thus  afforded  to  a  patient  who  for  months 
perhaps  has  been  compelled  to  use  a  catheter 
twelve  times  or  more  frequently  every  day  is  so 
great  that  he  often  desires  the  period  of  drainage 
to  be  prolonged,  and  thus  the  term  of  rest  to  be 
extended.  To  a  man  who  has  for  some  months 
before  never  enjoyed  two  consecutive  hours  of  sleep — 
and  in  some  of  these  long-standing  cases  the  term  of 
rest  does  not  even  reach  one  hour — the  ability  to  lie 
unmoved  and  be  undisturbed  for  an  unlimited  period 
of  time  constitutes  an  indulgence  which  he  appreciates 
to  the  utmost,  and  which  has  often  the  happiest  effect 
on  his  digestion,  his  strength,  and  his  spirits.  I  have 
seen  some  very  remarkable  examples  of  relief  arising 
from  the  process,  and  relief  of  a  permanent  character. 


24         ON  TUMOUES  OP  THE  BLADDER 

It  will  be  natural  in  this  place  to  advert  for  a  few: 
moments  to  the  analogous  operation  in  the  female 
when  dealing  with  obscure  forms  of  disease  for  the 
purposes  of  diagnosis  and  treatment.  In  order  to 
accomplish  a  digital  exploration  of  the  female  bladder 
all  that  is  needful  is  sufficient  dilatation  of  the  urethra 
to  admit  the  introduction  of  the  index  finger,  which 
may  be  accomplished  by  means  of  a  three-bladed 
dilator  or  otherwise,  after  which  the  facility  for 
examining  is  of  course  greater  than  that  attained 
after  perineal  incision  in  the  male.  Dilatation,  how- 
ever, always  comprehends,  I  think,  in  whatever  way 
it  is  rapidly  performed,  a  certain  amount  of  splitting 
or  rupture  of  the  urethra,  which,  however,  I  have 
never  known  to  be  followed  by  any  permanent  injury. 
I  have  thus  examined  five  cases  of  women  for  the 
purpose  of  diagnosis,  and  have  found  tumour  in  two, 
and  removed  both  without  any  further  enlargement 
of  the  opening. 

It  has  been  objected  by  some  that  when  the  pro- 
state is  largely  hypertrophied,  especially  in  a  fat  sub- 
ject, it  is  not  possible  to  explore  the  bladder  by  means 
of  the  proceeding  here  described.  Hypothetically  the 
objection  appears  important,  but  my  experience  shows 
that  the  difficulty  supposed  is  rarely  considerable  ; 
in  only  one  instance  have  I  failed  to  reach  the  whole 
of  the  internal  surface  of  the  cavity. 

If  only  the  ansesthesia  is  complete,  our  purpose  is 


DIGITAL    EXPLOEATION    OF    THE    BLADDER  25 

effected  mncli  more  easily  than  most  persons  would 
a  jyriori  imagine.  In  fact,  before  such  anaesthesia  had 
become  possible,  digital  exploration  of  the  bladder 
would  not  have  been  proposed,  and  certainly  could 
not  have  been  accomplished.  It  is  one  of  the  many 
applications  of  surgical  art  which  ovv^e  their  origin  solely 
to  that  influence.  For  if  absolute  and  complete  flac- 
cidity  of  the  abdominal  muscles  is  thus  attained,  it 
is  surprising  how  the  contents  of  the  pelvis  can  be 
pressed  down  towards  the  perineum  by  a  strong  and 
determined  assistant,  and  can  be  reached  by  the  opera- 
tor, however  large  the  prostate.  But  if  the  etherist 
permits  the  patient  any  power  of  resisting  with  the 
abdominal  muscles,  the  effort  is  hopeless,  and  failure  in 
the  attempt  to  explore  is,  I  believe,  more  likely  to  arise 
from  that  circumstance  than  from  any  other. 

Further,  it  cannot  be  frequently  necessary  to 
make  a  digital  exploration  in  cases  of  very  large  pro- 
state, inasmuch  as  the  cause  of  symptoms  is  generally 
sufficiently  patent,  and  therefore  does  not  call  for 
further  inquiry. 

The  bladder,  however,  may  require  to  be  drained 
in  advanced  disease  of  this  kind  ;  and  this  is  often 
done  with  great  and  permanent  benefit ;  for  which 
purpose  the  small  urethral  incision  suffices.  To  this 
proceeding  the  enlarged  prostate  offers  no  impedi- 
ment ;  but  complete  exploration  of  the  bladder  in 
such  a  case  is  not  required,  unless  unusual  symptoms 


26        ON  TUMOURS  OF  THE  BLADDER 

are  present,   which  the  enlargement  and  consequent 
obstruction  do  not  suffice  to  explain. 

Results. — I  shall  now  present,  in  brief  terms,  a 
list  of  all  the  cases  on  which  I  have  performed  digital 
exploration  of  the  bladder,  forty-three  in  number. 
In  twenty  of  these  tumour  was  found.  These  latter 
cases  will  only  be  named  here,  since  the  details  con- 
cerning them  will  be  fully  given  at  the  close  of  the 
fourth  chapter.  The  object  of  the  following  record 
is  to  indicate  all  the  various  conditions  for  which 
the  operation  of  digital  exploration  was  resorted  to, 
and  the  results  which  followed  its  performance. 

On  carefully  analysing  these  cases  there  appear  to 
be  four  chief  forms  of  vesical  disease,  in  which  the 
operation  of  opening  the  urethra  for  the  purpose  of 
withdrawing  the  urine  altogether  by  an  artificial 
route,  and  so  suspending  the  functions  both  of  the 
bladder  and  urethra  for  a  time,  may  render,  good 
service.  Then,  besides  these,  there  remains  a  fifth 
class  of  cases,  namely,  those  in  which  the  operation  is 
undertaken  solely  with  the  view  of  exploring,  when 
the  presence  of  tumour  may  be  strongly  suspected. 

The  first  class  consists  of  those  cases,  not  un- 
frequently  met  with,  in  which  all  the  symptoms  of 
chronic  cystitis  have  existed  for  a  long  period,  and 
in  a  severe  degree,  and  which  persist  in  spite  of 
long -continued  and  appropriate  treatment  ;  while  at 
the  same  time  it  is  understood  that  the  absence  of 


DIGITAL    EXPLORATION    OF    THE    BLADDER  27 

material  cause  for  the  cystitis,  such  as  stone,  stric- 
ture, vesical  incompetence,  &c.,  has  been  ascertained. 
Examples  are  Cases  2,  24,  31,  and  43. 

The  second  class  of  cases  includes  those  exam- 
ples of  prostatic  hypertrophy  and  of  atony  of  the 
bladder,  in  which  that  organ  must  be  emptied  by  th-e 
catheter  many  times  m  the  twenty-four  hours,  and 
in  which  painful  chronic  cystitis  is  obviously  aggra- 
vated, if  not  maintained,  by  the  necessary  process  of 
relief.  These  are  usually  cases  in  which  the  disease 
has  existed  for  years,  and  which  have  arrived,  to  all 
appearance,  at  the  latest  stage,  unless  complete  relief 
can  be  afforded.  Examples  are  seen  in  Cases  5 
and  34. 

The  third  class  embraces  those  cases,  less  rare 
perhaps  than  they  have  been  supposed  to  be,  in  which 
the  existence  of  impacted  calculus  or  of  adhering 
calculous  matter  may  be  suspected,  or  may  be  known 
to  be  present  by  sounding.  Examples  are  seen  in 
Cases  3,  4,  7,  22,  and  36. 

In  the  fourth  class  I  place  those  cases  in  which 
painful  and  very  frequent  micturition  or  bleeding, 
separately  or  combined,  may  have  long  existed ; 
without  signs  of  cystitis,  the  urine  being  clear,  free, 
or  nearly  so,  from  mucous  or  purulent  deposit ; 
furthermore,  the  cause  of  these  symptoms  has  baffled 
the  most  careful  inquiry.  On  exploration  being  made 
no  organic  change  is  discovered,  no  light  is  obtained 


28        ON  TUMOURS  OF  THE  BLADDER 

on  the  diagnosis  of  the  case,  but  the  functions  of  the 
bladder  and  urethra  are  suspended  for  a  week  or  so, 
and  the  patient  gets  well  more  or  less  completely. 
Of  this  remarkable  history  there  are  six  examples  in 
the  series :  of  which  three.  Cases  8,  14,  and  35,  per- 
fectly recovered,  besides  three  others  in  which  great 
improvement  took  place,  but  not  complete  recovery, 
Cases  17,  23,  and  41.  The  result  of  operation  under- 
taken in  the  circumstances  described,  as  a  last  if  not 
almost  hopeless  resource,  has  been  surprising,  and 
fraught  with  great  interest.  I  am  disposed  to  think 
that  there  are  some  persons  in  whom  an  attack  of 
cystitis  with  extreme  frequency  of  micturition  having 
been  set  up,  the  want  to  relieve  the  bladder  every 
half-hour  or  hour,  at  first  natural  and  necessary,  still 
continues  after  the  local  disease  has  passed  away,  in 
spite  of  their  efforts  to  overcome  it,  as  the  result  of 
what  may  be  regarded  as  persistency  of  a  morbid 
habit,  in  certain  constitutions.  I  cannot  further 
elucidate  the  pathological  condition  in  any  one  of 
them,  having  discovered  nothing  by  the  investigation 
to  account  for  the  symptoms. 

Besides  these,  one  case  has  been  already  referred 
to,  in  which  adhesions  between  the  mucous  lining  of 
the  bladder  were  separated  by  the  finger.  Case  12  ; 
there  was  one  case  of  division  of  the  neck  of  the 
bladder  which  was  extremely  tight  and  rigid,  Case 
41 ;  and  one  case  of  hagmaturia  in  which  the  surface 


DIGITAL    EXPLORATION    OF    THE    BLADDER  29 

of  the  mucous  membrane  was  studded  with  numerous 
minute  "villous  papillae,  removed  by  scraping,  followed 
by  applications  of  caustic,  Case  37.  In  each  of  these 
cases  considerable  improvement  resulted  from  the 
proceeding  ;  the  last  being  completely  successful. 

I  cannot  but  hope  that  the  results  reported  in 
these  histories  may  lead  to  a  further  employment  of 
this  simple  operation  in  cases  of  like  obscurity,  feel- 
ing sure  that  much  valuable  relief  to  suffering,  as  well 
as  prolongation  of  life,  may  be  attained  by  a  judicious 
application  of  the  proceeding. 


Forty-three  Cases  of  Operation  for  Digital  Exploration 
OF  the  Bladder,  'performed  by  the  author,  and  briefly 
reported,  but  containing  the  chief  points  of  the  history, 
progress,  and  results  in  each.  In  tiventy  instances, 
tumour  of  the  bladder  vjas  met  ivith ;  in  this  series  that 
fact  only  is  named ;  the  details  tvill  be  found  in  a  table 
at  the  end  of  the  fourth  chapter. 

Case  \.—T.  K.,  29.  Exploration:  1880,  November  6. 
Tumour  removed.     (See  Table,  No.  1.) 

Case  2. — J.  H.,  48.  For  several  years  has  passed  blood 
in  the  urine,  and  occasionally  phosphatic  deposits,  with  much 
frequency  of  micturition,  chronic  cystitis,  &c. 

Exploration:  1881,  June  27.  Nothiug  found ;  tube  re- 
mained a  week  for  drainage.  1884,  June  7.  Very  decided 
improvement  has  continued  ever  since. 

Case  3. — C.  J.,  52.  I  performed  lateral  lithotomy  in 
1880,  with  Dr.  Jas.  W.  J.  Smith,  of  Belfast,  for  a  large  uric 


30  DETAILS    OF    CASES    OF 

acid  calculus  :  the  wound  healed  slowly ;  subsequently  passed, 
phosphatic  masses  with  bleeding. 

Exploration:  1881,  June  17.  Found  phosphatic  deposit 
adhering  to  the  walls  of  the  bladder,  and  removed  it  with 
my  finger ;  then  drained  the  bladder  for  a  week  ;  some  relief 
followed,  but  it  was  not  considerable. 

Case  4. — T.  H.,  68.  A  year  ago  a  calculus  removed  from 
the  bladder  by  lithotomy.  Soon  after  recovery  he  had  hsema- 
turia,  continuing  some  months  in  spite  of  treatment.  He 
also  experienced  great  pain,  irritation,  and  extreme  weakness, 
his  condition  occasioning  great  anxiety. 

Exploration:  1882,  Feb.  10.  Nothing  found  except  a 
scale  of  phosphatic  matter,  adherent  to  the  bladder,  and  I 
removed  it  with  my  finger.  He  soon  recovered,  and  never 
saw  blood  again.  Was  seen  with  me  by  Sir  W.  Jenner. 
June,  1884.  He  called  on  me  three  months  ago,  stating  that 
he  was  enjoying  better  health  and  activity  than  for  years  past. 

Case  5. — T.  H.,  60.  Passes  all  urine  by  catheter,  many 
times  in  the  day  ;  much  phosphatic  deposit  and  great  suffer- 
ing. 

Exploration  :  1882,  March  20.  Nothing  whatever  found 
in  the  bladder.  I  therefore  introduced  a  tube,  which  re- 
mained there  eleven  days,  thoroughly  resting  and  draining 
the  bladder.  The  relief  was  great ;  he  resumed  active  habits, 
and  he  has  been  better  ever  since.  Drs.  Chepmell  and  Barton 
Smith  present. 

Case  6.— Mrs.  F.,  30.  Exploration:  1882,  May  9. 
Tumour  removed.     (See  Table,  No.  2.) 

Case  7. — A.  S.,  72.  Passes  all  urine  by  catheter,  with 
great  pain  and  extreme  frequency  ;  very  feeble ;  seen  in  con- 
sultation with  Sir  W.  Jenner. 

Exploration:  1882,  June  21.  I  found  a  small  impacted 
calculus,  and  removed  it  with  finger  ;  bladder  drained  through 
tube ;  great  relief  to  pain,  but  died  in  a  few  days  from  ex- 


DIGITAL    EXPLORATION    OF    THE    BLADDER  31 

haustion.  The  operation  was  undertaken  to  relieve  pain, 
and  not  with  any  view  of  saving  life,  as  he  was  obviously 
near  his  end. 

Case  8. — C.  C,  83.  Micturition  extremely  frequent  and 
very  painful,  but  requires  the  catheter  only  once  daily,  very 
little  urine  being  retained,  the  instrument  withdrawing  only 
one  ounce  and  that  is  clear. 

Exploration:  1882,  June  30.  Nothing  found;  tube  re- 
tained for  twelve  days,  after  which  the  relief  was  remarkable 
and  permanent.  I  have  recently  seen  him,  and  he  is  abso- 
lutely free  from  symptoms. 

Case  9. — B.  Gr.,  46.  Exploration:  1882,  November  3. 
Tumour  removed.     (See  Table,  No.  3.) 

Case  10.— M.  C,  52.  Exploration:  1882,  Nov.  20. 
Tumour  removed.     (See  Table,  No.  4.) 

Case  11. — F.  I.,  24.  History  of  severe  heemorrhage  and 
very  painful  frequent  micturition.  Sent  to  me  by  Dr.  lies,  of 
Fairford,  Grloucestershire. 

Exploration  :  1882,  Dec.  15.  Dr.  George  Johnson 
present.  Nothing  felt,  except  that  the  whole  cavity  of  the 
bladder  is  irregular  and  the  lining  membrane  thickened. 
Tube  retained  five  days  ;  on  removing  it,  bleeding  which  had 
ceased  reappeared.  The  wound  does  not  heal,  some  urine 
passing  by  it,  partially  prevented  by  frequent  catheterism. 

Case  12. — Mrs.  H.,  23.  From  New  Zealand,  with  very 
severe  symptoms  of  three  years'  standing ;  said  to  be  due  to 
'  polypus  of  bladder.' 

Exploration  :  1882,  Dec.  19.  Cavity  of  bladder  extremely 
small,  apparently  limited  by  adhesions,  w^hich  gave  way  easily 
under  pressure  of  the  finger  at  some  points  ;  a  condition  I 
never  observed  before ;  no  tumour.  She  soon  recovered,  lost 
all  pain  from  that  time,  but  was  compelled  to  pass  water 
almost  as  frequently  as  before.  Her  health  was  much  im- 
proved, and  she  returned  in  the  following  month. 


32  DETAILS    OF    CASES    OF 

Case  13. — E.  K.,  67.  Exploration:  1883,  January  17. 
Tumour  removed.     (See  Table,  No.  5.) 

Case  14. — W.  C,  52.  Very  frequent  and  painful  mictu- 
rition, without  ascertainable  cause,  for  a  year  past ;  rarely 
holds  water  more  than  half  an  hour.     No  haematuria. 

Exploration:  1883,  Jan.  22.  Dr.  Van  Syckel,  of  New 
York,  and  others  present.  No  morbid  sign  discoverable. 
Tube  retained  a  week.  Healed  quickly ;  being  one  month 
afterwards  absolutely  free  from  symptoms  ;  says  he  was  never 
better  in  his  life.  He  returned  to  the  Cape  of  Grood  Hope, 
whence  he  had  come  purposely  to  consult  me. 

Co,se  15. — Miss  G.,  30.  Severe  symptoms,  without  as- 
certainable cause.  Long-standing  haematuria,  evidently  from 
bladder.  Health  very  infirm ;  all  treatment  hitherto  em- 
ployed has  been  fruitless. 

Exploration :  1883,  Jan  .23.  Nothing  found,  but  thicken- 
ing of  mucous  membrane  of  bladder,  the  result  of  chronic 
cystitis.  No  relief  except  from  some  of  her  pain.  She  slowly 
sank,  and  died  within  a  month.  Sent  to  me  by  Dr.  Myrtle, 
of  Harrogate. 

Case  16.— T.  F.,  67.  Exploration:  1883,  January  30. 
Tumour  removed.     (See  Table,  No.  6.) 

Case  17. — W.  K.,  44.  Symptoms  severe.  Haematuria 
during  the  last  year  and  a  half;  no  cause  ascertainable. 

Exploration  :  1883,  Feb.  2.  Dr.  George  Johnson  present. 
Nothing  whatever  found  ;  tube  retained  four  days.  Wound 
healed  readily,  and  in  the  following  month  he  left  free  from 
symptoms.  Sent  to  me  by  Dr.  Appleyard,  of  Bradford.  I 
have  recently  learned  that  there  is  some  return  of  symptoms, 
although  much  less  considerable  than  before  the  operation. 

Case  18.— W.  W.,  63.  Exploration:  1883,  Februarys. 
Tumour  removed.     (See  Table,  No.  7.) 

Case  19.— J.  M.,  64.  Exploration:  1883,  Feb.  21. 
Tumour  removed.     (See  Table,  No.  8.) 


DIGITAL    EXPLORATION    OF    THE    BLADDER  33 

Case  20.— Mrs.  R.,  Q6.  Exploration:  1883,  Feb.  27. 
Tumour  removed.     (See  Table,  No.  9.) 

Case  21.— J.  S.,  53.  Exploration:  1883,  March  3. 
Tumour  removed.     (See  Table,  No.  10.) 

Case  22. — J.  F.,  27.  Very  severe  symptoms  for  four 
years  without  known  cause. 

Exploration  :  1883,  March  12.  I  found  the  upper  part 
of  bladder  coated  with  thin  phosphatic  deposit ;  and  detached 
a  quantity  which  proved  to  be  thin  flocculent  membrane 
with  adhering  phosphates,  and  was  scraped  off  with  my  finger 
nail,  when  it  became  free  in  the  bladder,  and  was  removed 
with  the  forceps.  I  at  first  supposed  it  to  be  a  slender 
villous  growth.  It  was  examined  by  Mr.  Eve,  who  described 
it  as  above.  Tube  was  retained  one  day ;  the  wound  did  not 
heal ;  he  had  orchitis,  and  suffered  much  for  a  long  time  ; 
ultimately  there  was  some  improvement. 

Case  23. — R.  B.,  50.  Severely  painful  and  frequent 
micturition  during  last  two  and  a  half  years ;  passes  urine 
every  hour,  day  and  night ;  occasionally  blood,  worse  for 
movements.  No  cause  being  discovered,  exploration  was 
made  1883,  March  15,  with  his  medical  attendant,  Mr.  J. 
Hartley,  Malton,  Yorkshire.  Nothing  was  found  but  rough- 
ness of  the  mucous  membrane,  not  considerable  in  places. 
No  fever,  not  much  bleeding;  tube  taken  out  on  third 
day,  gradual  improvement,  left  in  the  middle  of  April  much 
relieved.  June  1884.  Continues  to  be  troubled  with  undue 
frequency,  and  a  little  pain,  but  much  less  than  formerly. 
Health  good,  and  habits  active. 

Case  24.— C.  L.,  62.  In  1880,  October.  Lithotrity  for 
small  uric  acid  calculus,  single  sitting;  a  brief  operation, 
without  any  difficulty,  but  followed  by  severe  cystitis ; 
becoming  chronic,  and  attended  with  much  phosphatic 
deposit;  this  condition  continued  in  spite  of  treatment 
during  1881   and  1882,  phosphatic  concretions  being  occa- 

D 


34  DETAILS    OF    CASES    OF 

sionally  removed  by  lithotrite.  In  the  beginning  of  1883 
the  symptoms  were  more  severe  than  ever ;  urine  muco- 
purulent and  bloody,  and  no  cause  ascertained. 

Exploration :  1883,  March  21,  with  Sir  A.  Clark.  On 
the  right  side  of  the  prostate  a  firm  growth,  size  of  a  chest- 
nut with  broad  base,  protrudes  into  the  bladder.  Decided 
not  to  touch  it,  but  drained  the  bladder  for  some  days.  In 
the  middle  of  April  the  wound  healed,  and  a  little  improve- 
ment, certainly  not  much,  has  been  experienced  since. 

Case  25.— W.  D.,  Q5.  Exploration:  1883,  March  30. 
Tumour.     (See  Table,  No.  11.) 

Case  26. — J.  C.  D.,  43.  Pain,  frequency  and  repeated 
attacks  of  hsematuria,  more  or  less  during  five  years ;  symp- 
toms now  severe,  without  ascertainable  cause. 

Exploration  :  1883,  April  4.  Dr.  Stockton,  of  New  York, 
present.  Found  nothing  but  very  notable  roughness  at 
the  top  of  the  bladder,  like  phosphatic  incrustation,  but  on 
attempting  to  remove  it  with  finger  nail,  found  it  was  an 
altered  condition  of  mucous  membrane,  as  if  a  congeries  of 
varicose  vessels  with  thickened  walls ;  placed  a  tube  in  the 
wound.  On  the  fifth  day  signs  of  pyaemia  appeared,  and  he 
died  on  the  16th  ;  no  autopsy  permitted. 

Case  27.— C.  C.  S.,  56.  Exploration:  1883,  May  4. 
Tumour  removed.     (See  Table,  No.  12.) 

Case  28.— T.  Q.,  52.  Exploration:  1883,  May  9. 
Tumour  removed.     (See  Table,  No.  13.) 

Case  29.— A.  Gr.  S.  C,  57.  Exploration:  1883,  June  27. 
Tumour  removed.     (See  Table,  No.  14.) 

Case  30. — H.  B.,  23.  During  last  two  years,  subject 
to  pain,  frequency  and  slight  hsematuria,  little  influenced 
by  treatment,  and  associated  with  other  symptoms  of  an 
anomalous  kind ;  much  care  was  bestowed  on  the  case,  and 
no  explanation  of  it  was  discovered. 


DIGITAL    EXPLORATION    OF    THE    BLADDER  35 

Exploration:  1883,  June  28,  with  Dr.  Walker,  of  Lowes- 
toft. Nothing  whatever  found ;  tube  retained  eight  days. 
The  wound  healed,  and  he  left  in  a  month  with  less  fre- 
quency of  micturition,  but  with  constant  pain  in  the  penis, 
and  apparently  little  benefited  by  the  operation. 

Case  31. — E.  W.  C,  52.  Had  been  cut  for  a  large  stone 
in  May  1882  by  Dr.  Greo.  Buchanan,  of  Glasgow.  Wound 
healed  rapidly.  After  this,  great  pain  and  frequency  of 
micturition,  not  relieved  by  treatment. 

1883,  June  23.  Passes  water  every  twenty  minutes,  night 
and  day ;  worse  for  movement ;  phosphatic  deposits  and 
blood  in  the  urine ;  nothing  discovered  by  sounding  ;  empties 
his  bladder  perfectly.  I  thought  it  not  unlikely  that  some 
calculus  might  be  impacted  or  sacculated,  and  decided  to 
explore. 

Exploration :  June  29  ;  Dr.  Walker,  of  Lowestoft,  present. 
Nothing  found.  Ketained  tube  eight  days.  He  had  much 
subsequent  treatment  for  the  bladder,  and  he  left  in  about 
six  weeks,  retaining  urine  about  an  hour,  instead  of  twenty 
minutes,  a  very  slight  improvement. 

Case  32.— J.  H.  B.,  40.  Exploration  1883,  July  7. 
Tumour  removed.     (See  Table,  No.  15.) 

Case  33.— T.  S.,  42.  Exploration  1883,  November  16. 
Tumour  removed.     (See  Table,  No.  16.) 

Case  34.— H.  N.,  68;  October,  1882.  Last  four  years 
much  difficulty  and  pain  in  passing  water  ;  of  late  increasing. 
Now  passes  water  about  every  hour,  day  and  night.  Catheter 
passed,  forty  ounces  of  retained  urine ;  learned  to  use  the 
catheter.     Seen  with  Dr.  Barker,  of  Finsbury  Park. 

1883,  November,  greatly  relieved  by  catheterism  for 
several  months,  but  soon  felt  pain  when  the  bladder  was 
empty.  Sounded ;  phosphatic  calculus  found,  and  removed 
at  one  sitting.  Relief  at  first ;  subsequently  increased  pain 
and  frequency ;  all  urine  passes  by  catheter.     Decided  to 

D  2 


36  DETAILS    OF    CASES    OF 

explore  the  bladder,  and  did  so  December  11.  Nothing  was 
found,  but  the  bladder  very  rugose,  and  the  walls  thickened 
by  disease ;  it  was  drained  for  ten  days,  with  relief.  Wound 
soon  healed,  and  he  left  on  the  28th,  not  much  benefited. 
Not  long  afterwards  he  died,  worn  out  by  suffering. 

Case  35.— C.  H.  C,  25.  In  1881,  Feb.,  he  first  con- 
sulted me  for  attacks  of  ha3maturia,  commencing  two  years 
ago  after  severe  exercise.  Blood  appears  chiefly  at  the  end 
of  micturition  ;  always  after  exercise  or  standing.  Nothing 
found  by  sounding :  the  symptoms  strongly  indicate  tumour, 
although  no  debris  is  found  after  repeated  examinations  of 
the  urine. 

During  1883  lived  chiefly  on  board  his  yacht,  and  then 
rarely  saw  blood ;  but  this  still  appears  freely  after  exertion. 

1884,  Jan.  23.  Exploration  of  the  bladder:  Dr.  Greo. 
Johnson  and  Mr.  Bryant  present.  No  tumour  found ;  no 
organic  change  detected ;  retained  tube  nine  days.  There 
was  no  fever ;  health  excellent ;  wound  healed  by  February 
6.  In  the  middle  of  the  month  he  began  to  walk,  and  did 
so  for  two  hours  a  day  during  the  third  week,  without  any 
bleeding.  May,  1884.  He  is  now  perfectly  well ;  free  from  all 
symptoms. 

Case  36. — Mrs.  W.,  44.  1884,  Jan.  For  a  year  and  a 
quarter  micturition  has  been  very  frequent  and  painful, 
becoming  worse  of  late.  Has  had  much  treatment,  but  the 
cause  of  her  symptoms  is  obscure.  Jan.  26,  1884.  Explored 
the  bladder,  after  dilating  the  urethra,  with  Dr.  John  Smith, 
of  Dumfries,  who  brought  the  patient  up.  Found  springing 
from  the  centre  of  the  trigone  a  firm  prominence,  externally 
consisting  of  some  soft  structure,  and  almost  polypoid  in 
form,  but  on  drawing  it  forwards  in  the  attempt  to  ligature 
its  base,  this  outer  layer  was  first  scratched  through,  when 
a  hard  calculus  about  the  size  of  an  acorn  was  disclosed  and 
enucleated  ;  the  prominence  disappearing. 


DIGITAL    EXPLORATION    OF    THE    BLADDER  37 

She  had  long-continued  fever  with  much  exhaustion 
during  almost  a  month ;  but  gradually  recovered,  and  re- 
turned completely  relieved  from  her  urinary  troubles,  and  is 
now  quite  well ;  June,  1884. 

Case  37.— H.  F.,  58.  He  first  consulted  me  in  1879  for 
recurring  hsematuria,  to  which  he  had  already  been  subject 
three  years.  I  saw  him  from  time  to  time,  and,  finding  no  clue 
to  the  cause,  explored  the  bladder,  1884,  Jan.  30.  Mr.  Henry 
Morris  was  present.  Extremely  good  examples  of  villous 
growth  had  been  found  in  the  urine  when  examined  under 
microscope. 

At  the  operation  no  tumour  was  found,  but  numerous 
small  papillae  were  felt  affecting  the  upper  surface  and  sides 
of  the  bladder.  These  were  dealt  with  by  scraping  with  the 
finger  nail,  and  by  subsequent  injections  of  caustic.  He 
made  a  good  recovery,  and,  on  Feb.  20,  the  wound  was  quite 
healed ;  he  was  walking  out ;  no  frequency,  pain,  nor  bleed- 
ing present.  I  have  just  seen  him,  June  5  ;  he  was  walking 
four  miles  daily  without  any  of  his  former  symptoms. 

Case  38.— B.,  aged  50.  Exploration:  1884,  Feb.  5. 
Tumour  partially  removed.     (See  Table,  No.  17.) 

Case  39.— W.  Gr.,  aged  69.  Exploration  :  1884,  Mar.  12. 
Tumour  found.     (See  Table,  No.  18.) 

Case  40. — F.  J.  0.,  aged  58.  Exploration:  1884,  April 
4.     Tumour  found.     (See  Table,  No.  19.) 

Case  41. — M.  W.  B.,  aged  45.  Many  years  painful  symp- 
toms, and  treatment  for  alleged  stricture,  which  does  not 
exist.  During  last  twelve  months  great  frequency  of  mic- 
turition :  now,  every  half-hour,  night  and  day.  Instruments 
have  been  passed  by  himself  and  others  up  to  the  neck  of 
the  bladder,  and  then  fail  to  enter.  Examination  shows 
that  the  neck  of  the  bladder  is  distinctly  tense,  rigid  on  the 
lower   aspect,  but   the    short-beaked  sound    passes   over    it 


38  DIGITAL    EXPLOEATION    OF    THE    BLADDER 

readily  into  the  bladder ;  nevertheless,  there  is  no  stricture, 
for  No.  15  (English)  will  enter. 

1884,  April  14.  Exploration.  The  finger  on  entering  the 
bladder  encountered  rugae  and  a  roughened  surface  of  mucous 
membrane,  especially  at  upper  part  of  bladder.  The  neck 
of  the  bladder  was  exceedingly  tight,  grasping  the  end  of 
the  finger  like  a  ring;  I  divided  this  at  the  lower  border  so. 
that  the  tension  ceased.  Free  bleeding  followed.  A  tube 
was  tied  in  four  or  five  days.  He  recovered  slowly,  and 
gradually  regained  power  to  retain  his  urine  ;  the  intervals 
being  from  two  to  three  hours  in  the  middle  of  May — a 
condition  for  which  he  was  extremely  grateful.  He  takes 
out- door  exercise,  and  is  in  no  degree  worse  for  it. 

Case  42.— R.  S.  R.,  aged  63.  Exploration:  1884, 
May  30.  Tumour  found  and  removed.  (See  Table, 
No.  20.) 

Case  43. — W.  K.  E.,  aged  QQ.  Severe  symptoms  for 
some  time ;  prostate  very  large  and  irregular.  I  found 
a  phosphatic  calculus,  and  removed  it  May  19,  1884,  but 
very  little  relief  followed,  in  spite  of  daily  injections,  and 
much  treatment  of  various  kinds.  He  requires  frequent 
catheter]  sm,  but  the  intervals  are  very  short,  and  his  suffer- 
ing increased  during  the  first  week  in  June,  and  I  decided 
to  explore  the  bladder,  and  did  so  on  June  12.  No  frag- 
ments of  calculus  had  been  left,  but  I  found  prostatic  out- 
growth forming  a  salient  ridge,  broad,  and  overlapping 
the  base  and  sides  of  the  internal  meatus ;  tied  in  a  tube, 
and  exchanged  it  for  a  soft  catheter  next  day.  Great  relief 
followed  ;  he  retained  the  tube  eleven  days,  and  after  its 
withdrawal  held  his  water  two  to  three  hours.  June  28 : 
he  has  not  had  such  rest  at  night  for  several  months,  and 
the  urine,  which  was  highly  offensive,  and  loaded  with 
muco-pus,  is  now  comparatively  clear.  July  10  :  he  returns 
to  the  country  almost  well — better  than  I  ever  expected  to 
see  him.     Sent  to  me  by  Dr.  Sawyer,  of  Birmingham. 


39 


CHAPTER   III. 

TUMOURS  OF  THE  BLADDER,  THEIR  PHYSICAL  CHA- 
RACTERS AND  INTIMATE  STRUCTURE — SYMPTOMS 
AND    SIGNS    OF    THEIR    PRESENCE. 

History  of  operations  for  vesical  tumour  in  the  male — Examples  in  the 
metropolitan  museums — The  author's  cases — Intimate  structure — • 
Varieties— Symptoms — Physical  signs — Examination  of  the  urine. 

The  literary  history  of  vesical  tumours  is  scanty  ;  and 
inasmucli  as,  with  few  exceptions,  its  earlier  records 
treat  the  familiar  outgrowths  from  the  prostate,  and 
the  rarer  neoplasms  which  arise  from  the  bladder, 
without  distinguishing  between  them,  not  much  is 
available  for  our  purpose. 

More  than  one  attempt  has  been  made  of  late  to 
cpllect  all  the  cases  which  may  be  hunted  up  among 
old  authors,  with  the  laudable  view  of  collecting  in- 
formation on  a  subject  so  lately  fraught  with  new 
interest,  but  the  result  is  not  successful.  The  material 
which  has  thus  been  apparently  gained  as  regards 
quantity  by  somewhat  indiscriminately  sweeping  the 
dusty  pages  of  old  surgical  writers,  in  the  keen 
search  for  any  semblance  of  a  vesical  tumour,  is  found 


40        ON  TUMOURS  OF  THE  BLADDER 

to  possess  little  value,  from  the  uncertain  quality  of 
the  produce  so  gathered.  The  only  object  worth 
attaining  by  antiquarian  research  is  the  discovery  of 
undoubted  examples  of  true  vesical  growths,  and  of 
some  important  facts  respecting  them,  and  not  the 
production  of  a  list,  the  extent  of  which  suggests 
erudition,  but  is  due  to  a  miscellaneous  collection  of 
records  embracing  mere  prostatic  outgrowths  on  the 
one  hand,  and  cancerous  formations  on  the  other, 
indiscriminately  mixed  with  all  the  varied  products 
which  lie  between  them. 

Carefully  eliminating  obviously  useless  matter,  I 
will  give  a  brief  historical  epitome  of  the  few  unques- 
tionable operations  made  for  the  purpose  of  removing 
recognised  tumours  of  the  bladder,  with  a  view  of 
showing  what  surgery  has  hitherto  done  in  the  way 
of  removing  them. 

History. — There  is  no  doubt  that  Covillard,  of 
Lyons,  performed  the  lateral  operation  for  a  vesical 
tumour  proper,  in  the  year  1639,  having  previously 
diagnosed,  by  sounding,  the  presence  of  '  un  corps  dur 
et  solide,'  not  a  stone.  He  describes  how  he  crushed 
it  with  the  forceps,  destroying  and  removing  it,  and 
records  that  the  patient  recovered.^ 

The  occurrence  of  flocculent,  sprouting  grovfths, 
as    well   as   of  more    solid   growths  from  the  neck 

^  Le  Cliirnrgien   operateur :  avec  des  observ.  iatrochirurgiqties,  par 
Joseph  Covillard.     8vo.  Lyons,  1640. 


HISTORY    OF    OPERATIONS    FOR  41 

of  the  bladder  (prostatic)  was  well  known  to 
the  older  surgeons.  Le  Cat  refers  to  them,  and 
to  some  observations  made  respecting  them  by 
Ruysch,  Houstet,  Le  Dran,  and  others.^  In  the 
end  of  the  last  century,  Deschamps,  Boyer,  Gruerin 
(pere),  and  Desault,  besides  others,  refer  to  vesical 
outgrowths,  but  Ghopart  offers  the  best  descrip- 
tion of  them  under  the  head  of  '  Fungus  of  the 
Bladder'  in  his  classical  work,  and  here  vascular 
papilloma  is  distinctly  described  as  differing  from  the 
malignant  and  other  forms. ^  Furthermore,  he  re- 
lates the  case  in  which  Desault,  towards  the  close  of 
the  last  century,  recognised  a  pedunculated  growth  of 
considerable  size  in  the  bladder  of  a  patient,  as  he 
was  cutting  for  the  stone  in  Hotel  Dieu  ;  and  relates 
that,  after  removmg  it,  he  twisted  off  the  tumour  with 
the  lithotomy  forceps,  and  that  the  patient  made  a 
good  recovery.^  Then,  very  early  in  the  present 
century,  A.  Petit,  of  Lyons,  operating  on  a  man  aged 
28,  supposed  to  have  the  stone,  found  a  large  tumour, 
which,  after  consultation,  was  left  untouched.  The 
patient  recovered  from  the  operation,  but  returned  to 
the  hospital  after  a  year  to  die,  and  at  the  autopsy 
the  tumour  was  found  to  be  of  the  size  of  a  fist,  and 

^  Parallele  de  la  taille  laterale.     Amsterdam,  1766,  pp.  244-61. 

^  Traits  des  maladies  des  voies  urinaires,  par  Chopart.  A  post- 
humous edition,  edited  by  Felix  Pascal.  Paris,  1830  ;  vol.  ii.  pp. 
74-79.     Chopart  and  Desault  both  died  in  1795. 

^  Idem,  vol.  ii.  p.  97. 


42        ON  TUMOURS  OF  THE  BLADDEE 

attached  by  a  small  pedicle  which  might  have  been 
easily  divided/ 

The  next  definite  record  is  by  Civiale,  who 
refers  to  three  instances  in  which,  subsequently  to 
1827,  he  removed  small  growths  from  the  bladder 
evidently  unimportant  in  size,  with  his  original  '  tri- 
labe,'  when  crushing  the  stone,  without  any  bad 
results.  He  also  describes  a  similar  operation  on  a 
fourth,  much  larger,  the  result  of  which  was  unsuc- 
cessful, and  another  case  in  H6pital  Neckar,  treated 
in  the  same  manner,  in  1834,  with  good  result,  add- 
ing that  he  has  crushed  other  small  ones  with  the 
lithotrite.^  The  nature  of  these  operations  necessarily 
precluded  intelligent  observation,  or  the  acquisition 
of  information  respecting  the  growths  themselves  ; 
and  very  little,  if  anything,  is  known  of  the  ultimate 
history  of  the  patients. 

In  1834  Crosse,  of  Norwich,  operated  on  a  boy 
with  severe  symptoms  of  calculus,  by  the  lateral 
operation,  although  on  sounding  he  could  find  none, 
but  several  small  tumours  protruded  from  the  wound, 
some  of  which  he  removed.  The  boy  died  in  forty- 
eight  hours,  and  a  number  of  these  growths  was  found 
in  the  bladder.  The  preparation  is  No.  2000  in  the 
Hunterian  Museum  here.^ 

^  Diet,  des  Sciences  Medicales,  vol,  xliv.  pp.  232-33.  Paris,  1820. 
Article  '  Polype,'  by  Vaidy. 

^  Traite  pratique,  vol.  iii.  pp.  152-61.     Paris,  1860. 

^  Treatise  on  Calculus,  by  J.  G.  Crosse,  surgeon  to  the  Norfolk  and 
Norwich  Hospital ;  plate  xx.  fig.  2,  p.  124.     London,  1835. 


HISTORY    or    OPERATIONS    FOR  43 

In  1874,  Billroth,  of  Vienna,  did  the  lateral  opera- 
tion on  a  boy  of  twelve  to  remove  a  tumour,  a  '  myo- 
sarcoma '  of  large  size  ;  findmg  the  opening  insuffi- 
cient, he  performed  the  suprapubic  operation,  and 
extracted  it  there.     The  boy  made  a  good  recovery/ 

In  the  same  year  Volkmann,  of  Halle,  did  the 
suprapubic  operation  for  a  man  aged  54,  removing  a 
large  myomatous  growth,  with  a  small  pedicle  only 
half  an  inch  long,  the  patient  dying  of  infiltration 
and  peritonitis  on  the  third  day.^ 

Professor  Kocher,  of  Berne,  performed  Nelaton's 
pre-rectal  lithotomy,  December  31,  1874,  for  a  man 
aged  38,  for  the  removal  of  a  papilloma.  The  man 
was  reported  well  one  and  a  quarter  year  afterwards.^ 

At  Addenbrooke's  Hospital,  Cambridge,  Professor 
Murray  Humphry  did  lateral  lithotomy,  October  17, 
1877,  for  a  man  aged  21,  removing  a  large  tumour 
completely,  the  man  recovering.* 

Suprapubic  lithotomy  was  done  by  Marcacci  on 
a  man  aged  54  for  vesical  tumour  in  1880.  It  was 
villous  on  the  surface,  but  it  was  stated  to  be  a 
'  spindle -celled  sarcoma  '  throughout.  He  lived  two 
months,  dying  of  extravasation  and  peritonitis.^ 

Berkeley   Hill    performed   lateral    lithotomy    at 

^  Archiv  fiir  hlinische  CJiirurgie,  band  xviii.,  1875. 

^  Ihid.,  band  xix.  p.  682,  1876. 

^  Centralblatt  fur  Chirurgie,  April  1,  1876. 

*  Medico-Chirurg.  Trans.,  vol.  Ixii.  pp.  421-27.     1879. 

^  Lo  Sperimentale,  Oct.  1880 ;  London  Medical  Record,  Dec.  1880. 


44         ON  TUMOURS  OF  THE  BLADDER 

University  College  Hospital  in  1880,  removing  a 
portion  of  an  epithelioma,  in  a  man  aged  63,  who  died 
two  days  after. ^ 

Davies  Colley,  of  Guy's  Hospital,  performed  lateral 
lithotomy  in  April  1880,  for  a  man  aged  32,  drawing 
out  a  long  villous  growth,  and  cutting  it  off  with  a 
pair  of  scissors  close  to  the  wall  of  the  bladder.^  Mr. 
Colley  has  just  written  me  (May  1,  1884)  that  the 
man  is  at  this  time  perfectly  well,  and  has  followed 
his  occupation — that  of  a  shipwright — ever  since. 

The  first  case  in  which  I  myself  removed  a 
tumour  by  operation  was  that  of  a  man  aged  29,  on 
whom  I  did  the  median  operation,  November  6,  1880. 
I  found  a  polypoid  growth  and  removed  the  whole  of 
it  with  a  pair  of  forceps,  twisting  it  oiF  at  the  base  of 
the  pedicle.  He  made  a  rapid  recovery,  and  is  living 
and  well  at  the  present  time.^ 

My  subsequent  cases — 19  in  number,  17  in  males, 
as  well  as  2  in  females,  all  the  former  having  been 
discovered  by  digital  exploration  of  the  bladder,  and 
treated  by  the  limited  perineal  incision  employed  for 
that  purpose — will  be  furnished  in  a  table  to  be  con- 
sidered presently. 

Mr.  Whitehead,  of  Manchester,  has  adopted  this 
method  of  treatment,  and  employed  it  with  consider- 

^  Report  of  Surgical  Registrar,  Mr.  Stanley  Boyd,  1880.     London  : 
Harrison,  1881,  p.  33. 

2  Clin.  Soc.  Trans.,  vol.  xiv.  p.  104.     1881. 

3  Trans.  Med.  Ghir.,  vol.  Ixv.     1822. 


HISTOEY    OF    OPERATIONS    FOR  45 

able  success.  He  has  recently,  in  conjunction  with 
Dr.  Pollard,  published  six  cases  of  operation  for 
vesical  tumoar,  four  in  the  uiale,  and  two  in  the 
female.  In  two  of  the  former  a  very  favourable  con- 
dition of  the  patient  is  reported  nearly  twelve  months 
after  operation,  and  the  female  cases,  more  recent, 
were  well  at  the  date  of  the  report.^ 

Certain  other  cases  found  recorded  in  the  j  ournals 
have  been  quoted  by  recent  writers  as  examples  of 
operation  for  vesical  tumour,  but  are  intentionally 
omitted  here,  since  the  operations  in  question  have 
either  failed  entirely  or  partially  to  remove  the 
tumour,  or  no  such  body  has  been  present.^ 

It  is  also  unnecessary  to  refer  further  to  the 
history  of  operations  for  vesical  growths  in  the 
female,  since  they  have  been  long  recognised  as  ac- 
cessible to  examination  and  amenable  to  surgical  treat- 
ment without  much  difficulty.  The  well-known 
case  by  Surgeon  Warner,  of  Guy's  Hospital,  in  the 
former  half  of  last  century,  occurred  in  a  woman 
aged  24.     He  divided  the  neck  of  the  bladder  and 

^  The  Surgical  Treatment  of  Tumours,  d;c. ,  by  W.  Whitehead  and 
Dr.  B.  Pollard  (London  :  Churchill,  1883)  ;  containing  much  inter- 
esting matter,  and  valuable  information  on  the  subject. 

^  Thus  Gersuny,  Billroth's  assistant  at  Vienna,  performed  the 
median  operation  in  the  winter  of  1870-1,  to  remove  a  broken  piece 
of  catheter,  and  discovered  a  tumour,  which  could  not  be  removed, 
and  no  attempt  was  therefore  made.  The  patient  died  six  days  after, 
and  the  tumour  was  found  at  the  autopsy  in  a  recess  at  the  back  of  the 
bladder.  But  clearly  this  is  not  an  operation  for  tumour. — Aixhiv 
fur  klinische  Chirurgie,  band  xiii.  p.  131.     1871. 


46        ON  TUMOURS  OE  THE  BLADDER 

ligatured  a  large  polypoid  tumour  with  a  successful 
result.^ 

From  the  numerous  well-known  facts  of  a  similar 
kind,  and  from  the  short  list  of  operations  on  the 
male  above  recorded,  it  is  quite  certain  that  a  consider- 
able proportion  of  vesical  tumours  are  removable,  and 
that  when  completely  or  almost  completely  removed 
they  often  do  not  reappear.  That  is  all  which  we 
gain  from  the  study  of  the  slender  experience  of  the 
past,  and,  so  far  as  it  goes,  it  is  not  without  value. 

Examples  in  Museums. — But  there  is  another 
mode  of  studying  the  subject  which  has  not  been 
pursued  to  any  great  extent,  and  which  nevertheless 
is  fraught  with  greater  promise ;  a  mode,  indeed, 
which  it  is  only  possible  to  pursue  on  an  extensive 
scale  in  this  country,  since  here  only  the  requisite 
materials  are  to  be  found — I  mean  the  study  of  the 
vesical  tumours  themselves,  with  their  physical  charac- 
ters exposed  to  view,  as  found  in  the  various  museums 
of  our  metropolis,  together  with,  in  many  instances, 
a  few  important  facts  relating  to  the  character  and 
history  of  those  who  were  the  subjects  of  the  disease. 
It  is  among  these  important  collections  that  we  find 
the  originals  of  those  drawings  which  have  served  to 
familiarise  the  student,  both  here  and  abroad,  with 
delineations  of  disease  which  they  are  rarely  able  to 

^  Cases  in  Surgery,  by  Joseph  Warner,  F.R.S.,  Surgeon  to  Guy's 
Hospital  (London,  1750)  ;  and  Philosoph.  Trans.,  vol.  xliv. 


EXAMPLES    OE,    IN    MUSEUMS  47 

see  or  dissect,  Here  are  the  very  organs  which  were 
engraved  for  the  works  of  Baillie,  Hunter,  Bell, 
Home,  Crosse,  and  others  and  from  which  Civiale 
selected  his  subjects  to  illustrate  the  '  Traite  pratique ' 
in  connection  with  this  topic. ^ 

Of  growths  or  tumours  arising  from  the  inner 
surface  of  the  bladder  and  pursuing  an  independent 
development  within  the  cavity,  there  were  in  the 
metropolitan  museums,  prior  to  1882,  about  fifty 
examples  preserved  in  spirit. 

Forty- three  of  these  were  from  adults  of  various 
ages  ;  eight  had  occurred  m  young  children.  A 
large  majority  of  the  former  or  adult  series  had  arisen 
in  male  patients  ;  but  as  in  a  few  preparations  the 
sex  is  uncertain,  no  exact  statement  can  be  made. 
Of  the  eight  children,  six  were  female.  In  addition 
to  these  fifty  cases  there  is  about  an  equal  number 
of  growths  and  infiltrations  preserved  in  the  same 
museums,  which  are  probably  cancerous,  and  respect- 
ins*  which  there  is  little  more  to  be  said.  Returning; 
to  the  non-cancerous  growths  it  may  be  stated  that; 
in  respect  of  physical  conformation,  a  considerable 
proportion  of  them  consist  of  a  single  growth  from 
the  walls  of  the  bladder,  more  or  less  pedunculated  ; 
and  might  obviously  have  been  removed  by  operation 
without  difiiculty.  Others  are  broad  and  sessile, 
developed  into  two  or  more  lobes  ;  and  much  more 

^  Traite  pratique,  vol.  iii.  pp.  107  et  seq.,  figs.  9-13.     Paris,  1860. 


48 


ON  TUMOURS  OF  THE  BLADDER 


rarely  tbere  are  two  or  more  independent  growths 
in  the  same  bladder.     Then  some  are  delicate,  soft, 


Fig.  4. — Two  growths,  probably  fibro-papilloma.     From  preparation 
No.  2006,  Royal  College  of  Surgeons. 


Fig.  5. — From  a  man  aged  59.  The  tumour,  which  was  of  rapid 
growth,  springs  from  a  narrow  base.  As  here  seen,  it  iills  the 
bladder,  is  chiefly  solid,  but  covered  with  fimbriated  papilloma. 
From  prep.  No.  200i,  Museum,  Royal  College  of  Surgeons. 
A  very  similar  preparation  may  be  seen  at  University  College 
Museum,  No.  1475. 


TYPICAL    EXAMPLES    OE 


49 


filamentous  or  fimbriated  in  structure  ;  while  others 
are  firm  and  solid  ;  much  variety  of  density  is  to  be 


Fig.  6. — Firm  polypeid  growths,  each  with  very  narrow  peduncle. 
Bladder  everted  to  show  them ;  no  papillte  present.  From 
Museum  of  Guy's  Hospital,  No.  2104^8. 


Fig.  7. — Small,  firm,  almost  polypoid  growth. 

met   with   among   different    specimens   in   the  fi:'esh 
state,  as  my  own  cases  have  led  me  to  observe. 

E 


50         ON  TUMOUES  OE  THE  BLADDER 

In  relation  to  the  question  of  situation,  it  does 
not  appear  that  any  part  of  the  bladder  can  be 
regarded  as  a  particularly  favourite  spot  for  their 
origin  ;  the  orifices  of  the  ureters,  for  example,  as  is 
stated  by  some.  The  lower  half  of  the  bladder  is 
more  frequently  affected  than  the  upper ;  and  I  think 
that  is  the  only  distinct  statement  relating  to  locality 
which  can  be  made. 

I  have  selected  several  of  the  most  typical  varieties 
and  have  made  drawings  from  them  which  have  been 
engraved  in  order  to  illustrate  the  subject  of  size, 
contour,  and  number,  so  important  in  relation  to 
questions  of  surgical  treatment,  hereafter  to  be  con- 
sidered (see  figs.  4,  5,  6,  7  ;  also  1,  9,  and  10). 

The  Author's  Cases. — Next  to  the  preserved 
examples  may  be  considered  the  result  of  my  own 
experience,  derived  from  exploring  the  bladder,  in 
the  manner  described  in  the  preceding  chapter.  By 
means  of  this  operation  I  have  already  encountered 
no  less  than  twenty  cases  of  vesical  tumour.  At  the 
end  of  the  volume  will  be  found  an  account  of  them 
in  a  tabular  form,  which  shows  at  a  glance  the  fol- 
lowing particulars  :  the  age  of  the  patient,  the  date 
of  operation,  the  duration  of  symptoms  up  to  that 
period,  what  was  the  earliest  symptom  observed,  the 
result  of  examination  of  the  urine  before  operation, 
the  nature  of  the  operation  itself,  the  form  and 
situation  of  the  tumour,  its  structural  elements  after 


THE    author's    cases  51 

examination,    and   the   after   results  to  tlie   present 
time. 

In  some  cases  I  have,  as  far  as  the  sense  of  touch 
has  enabled  me  to  judge,  removed  the  entire  growth, 
and  when  unable  to  do  so  have  taken  away  as 
much  of  it  as  possible  ;  pruning,  so  to  speak,  the 
most  salient  portions,  when  the  growth  was  insepa- 
rable from  the  walls  of  the  bladder,  a  condition,  met 
with  in  several  cases.  In  all  instances,  however,  I 
have  been  very  careful  to  examine  the  growth  so 
minutely  with  the  finger  before  operating,  as  to  be 
able  to  offer  a  diagrammatic  representation  of  its  size 
and  form.  In  each  one  of  these  cases  I  made  a 
sketch  at  the  time,  representing  to  the  best  of  my 
ability  the  impression  thus  obtained  of  the  contour 
and  situation  of  the  growth  iia  relation  to  the  vesical 
cavity.  These  are  reproduced  here  in  order  to  illus- 
trate each  case  when  referred  to  ;  and  thus  fresh 
information  in  regard  of  the  conditions  likely  to  be 
met  with  in  such  cases  has  been  obtained.  I  think 
in  general  terms  it  may  be  affirmed  that  a  single 
tumour  attached  by  a  narrow  pedicle  to  the  wall  of 
the  bladder,  and  therefore  resembling  more  or  less 
the  outline  of  a  fig,  is  not  very  common,  and  to  say 
that  it  may  occur  once  in  six  or  seven  cases  of 
non-malignant  tumour  probably  approaches  a  cor- 
rect numerical  estimate.  On  the  other  hand,  sessile 
growths,  of  which  the  base  is  perhaps  the   widest 

E  2 


52         ON  TUMOURS  OE  THE  BLADDER 

part,  are  met  with,  perhaps  quite  as  frequently  as  the 
pedunculated  form  just  described  :  and  then  there 
are  intermediate  forms  of  every  grade  between  the 
two  ;  the  preponderance  in  number  perhaps  being 
among  the  non-pedunculated  class. 

Structure. — We  now  come  to  structural  charac- 
ters. Hitherto  most  of  the  statements  relative  to  vesi- 
cal growths  have  been  somewhat  vague,  since  mate- 
rials for  observation  have  not  been  attainable.  Thus 
it  has  been  customary  to  regard  '  villous '  growths  as 
a  class  ;  and  these  were  at  no  very  remote  period 
termed  '  villous  cancer.'  The  existence  of  papilloma 
has  been  generally  recognised  ;  occasionally  sarco- 
matous growths  have  been  spoken  of,  although 
probably  without  intention  to  convey  the  meaning 
which  modern  pathology  attaches  to  the  term.  After 
that,  follow  epithelioma  and  cancer.  Then  occa- 
sionally, but  rarely,  an  isolated  specimen  has  appeared 
at  the  Pathological  Society  of  London,  and  has  been 
subjected  to  a  minute  examination,  but  the  total  of 
these  specimens  has  not  afforded  data  for  making  any 
classification.  Neither  at  present  is  it  possible  to 
form  a  complete  generalisation,  but  valuable  indica- 
tions have  been  attained  from  the  twenty  cases  now 
brought  before  you,  which  indicate  a  sufficient  number 
of  important  facts  to  commence  with.  Every  one  of 
the  tumours  I  have  dealt  with,  including  the  few  which 
have  not  been  removed  (since  I  have  invariably  taken 


THEIR    NATURE    AND    INTIMATE    STRUCTURE  53 

away  a  portion  sufficiently  large  for  complete  histo- 
logical examination),  has  been  carefully  treated  by  a 
competent  observer,  at  first  by  Mr.  Stanley  Boyd, 
with  one  or  two  by  Mr.  Eve,  and  others  by  Mr. 
Shattock,  while  all  the  later  ones  (fourteen  in  number) 
have  been  laboriously  investigated  for  me  by  Dr. 
Heneage  Gibbes,  from  whom  I  have  received  in  every 
instance  a  full  written  report  on  intimate  struc- 
ture and  several  microscopic  preparations,  some  of 
which  furnished  the  originals  of  some  very  accurate 
and  beautiful  drawings,  made  and  engraved  by  Mr. 
T.  P.  CoUings,  and  presented  here. 

After  a  survey  of  the  museum  specimens  on  the 
one  hand,  and  a  consideration  of  the  facts  determined 
by  histological  analysis  of  my  own  cases  on  the 
other,  with  Dr.  Heneage  Gibbes,  I  have  made  the 
following  attempt  at  classifying  these  products,  and 
I  think  it  will  be  regarded  as  warranted  by  the 
evidence. 

First,  there  is  the  simple  mucous  polypus  which  I 
have  at  present  only  found  in  the  bladder  of  children, 
and  in  their  cases  only  among  the  preparations  in  the 
museums  referred  to — some  of  which  appear  to  be 
analogous  in  structure  to  the  soft  nasal  polypus,  a 
form  of  myxoma,  while  other  specimens  appear  to 
contain,  in  addition,  more  of  the  deeper  normal  fibres 
of  the  structures  from  which  the  growth  arises.  In 
the  specimens  referred  to,  of  which  one  was  engraved 


54         ON  TUMOUES  OF  THE  BLADDER 

in  Crosse's  work,  and  another  is  presented  here  (fig. 
8)  ;   the   growths    are   numerous,  evidently   rapidly 


Fig.  8. — Poljpoid  growths  (myxoma),  from  a  child  1^  year  old, 
under  Mr.  Marshall  at  University  College  Hospital.  From. 
Museum,  No.  1471  E. 

formed,  soon  fill  the  bladder,  and  in  the  case  of 
female  children  sometimes  issue  by  the  external 
meatus,  and  present  in  the  vagina.^ 

The   operators    have   described    the   first-named 

^  One  example  of  polypoid  growths  in  a  child  is  given  in  Dr.  M. 
Baillie's  series  of  engravings  illustrating  the  morbid  anatomy  of  the 
human  body,  &c.  (London,  1799,  fasc.  vii.  vol.  iv.  fig.  2,  p.  151). 
This  is  now  Prep.  No.  1999  R.C.S.  Museum.  Crosse's  example  is 
shown  at  pi.  xx.  fig.  2  of  the  Treatise  on  Calculus  (London,  1835),  and 
is  Prep.  No.  2000  in  the  same  museum.  Three  other  specimens  are 
in  Guy's  Hospital  Museum  :  one,  a  girl  aged  five  years — No.  2104  ^° — 
described  by  Mr.  Birkett  in  Trans.  Med.  Chir.  Soc,  vol.  xli.  p.  311 ; 
another,  2104  ^2 ;  and  a  boy,  No.  2104  ^\ 

One  is  in  St.  Bartholomew's  Museum,  2419,  described  in  Fath.  Soc. 
Trans.,  vol.  iii.  p.  127  ;  one  in  St.  Thomas's,  B  B  28  ;  and  one  in 
University  College,  1471  e,  carefully  described  in  Path.  Trans.,  vol. 
xxxiv.  pp.  150-1 — by  Mr.  S.  Gr.  Shattock.  An  interesting  case  is 
reported  by  Mr.  Howard  Marsh  in  the  Path.  Soc.  Trans.,  vol.  xxv. 
pp.  178-80,  carefully  examined  by  Mr.  Butlin  and  by  Mr.  M.  Beck. 


AS    APPEARING    IN    CHILDEEN  55 

kind  when  fresh  as  soft,  gelatinous,  and  translucent ; 
conditions  which  are  lost  in  the  preparation  by 
immersion  in  spirit. 

In  all  but  one  of  the  eight  cases  in  the  museums 
the  age  was  two  years  or  less,  and  in  the  exception 
was  five  years  only.  It  is  not  unlikely  that  some  of 
these  may  be  congenital,  while  the  structure  shows 
them  to  be  composed  of  embryonic  elements.  I  have 
never  met  with  anything  of  this  kind  in  the  adult 
bladder. 

Two  of  the  more  recent  specimens  have  been 
carefully  examined  and  reported  on  at  the  Patholo- 
gical Society,  and  are  referred  to  m  the  note  below, 
forming  in  fact  the  two  specimens  last  on  the  list 
there  given.  One,  examined  by  Mr.  Butlin  and  Mr. 
Beck,  was  '  found  to  be  composed  almost  entirely  of 
small  round  cells  of  a  lymphoid  type  embedded  in  a 
basis,  homogeneous  or  nearly  so  on  the  surface,  but 
becoming  more  and  more  fibrous  towards  the  pedicle, 
until  at  the  base  the  fibrous  tissue  forms  the  bulk  of 
the  growth,  the  cells  being  only  scattered  here  and 
there,  either  singly  or  in  groups.'  The  other,  exa- 
mined by  Mr.  Shattock,  is  described  as  displaying 
'  oval  and  more  elongated  cells  lying  in  an  abundant 
intercellular  substance,  either  albuminous  or  mucous, 
and  scantily  traversed  by  fibres  ;  no  stellate  cells  are 
present.' 

In  regard  to  the  cases  of  vesical  tumour  in  which 


56         ON  TUMOURS  OF  THE  BLADDEE 

I  have  myself  operated,  tliey  fall  naturally,  as  do 
those  of  other  regions,  into  two  distinct  categories  : 
namely,  those  which  consist  only  of  elements  iden- 
tical with  the  normal  tissues  of  the  bladder,  '  homoeo- 
plastic '  ;  and  those  which  consist,  more  or  less,  of 
other  elements  never  found  in  the  tissues  of  the 
healthy  bladder,  or  '  heteroplastic' 

The  first  category  offers  at  least  three  forms  of 
growth,  but  passing  insensibly  from  one  to  the  other, 
being  apparently  diverse  developments  of  the  same 
structural  change.  Two  of  them  may  be  spoken  of 
as  papilloma,  which  appears  in  two  typical  forms. 
Before  describing  them  I  shall  give  a  representation  of 
healthy  vesical  mucous  membrane  for  the  purpose  of 
comparing  the  epithelium  and  its  underlying  tissues 
in  the  bladder  with  the  analogous  tissues  in  papil- 
loma. It  is  a  drawing  from  a  very  successful  section 
made  immediately  after  death  from  the  emptied 
bladder  of  an  ape  by  Dr.  Gibbes  (Plate  I.).  It  shows 
a  minute  fold  of  the  mucous  membrane,  resulting 
from  that  duplicature  of  it  which  takes  place  when 
the  bladder  is  contracted.  And  thus  it  has,  in  this 
temporary  condition,  a  strong  resemblance  to  the 
permanent  form  which  a  single  papilla  exhibits  when 
papillomatous  growth  is  present  in  the  bladder. 

1.  Fimbriated  Papilloma. — I  employ  this  term 
to  designate  that  product  which  has  been  familiarly 
known  as  the  '  villous '  growth,  which  is   admitted 


PLATE   ]. 


C"} 


\ 


Section  of  Healthy  Mucous  Membeiake,  jiade  dib,ectly  afu'er  Death, 
FROM  THE  Ape  :  showing  Natural  Poldisg  of  the  Membraxe  in  thk 
emptied  Condition  op  the  Bladder,  and  the  resemblance  the  Fold 
bears  to  a  Papilla:  x  IGO. 


FIMBKIATED    PAPILLOMA  57 

to  be  objectionable  on  several  grounds.  The  most 
obvious  character  of  the  growth  is  a  structure  in 
which  the  vesical  mucous  membrane  is  developed 
into  fine  papillas,  which  consist  of  long  fimbriated 
processes  of  extreme  tenuity,  and  usually  form  a 
group  arising  from  a  small  circumscribed  base. 
This  last-named  part  contains  other  and  more  solid 
structure  than  that  which  enters  into  the  papillas 
themselves.  Sometimes  the  processes  are  almost 
single  thread-like  forms,  arranged  side  by  side,  and 
undivided  for  a  considerable  distance ;  others  are 
bifid,  generally  more  compound  still ;  some  may  be 
described  as  digitate,  and  occasionally  the  processes 
radiate  and  suggest  forms  resembling  those  of  leaves. 
Immersed  in  fluid,  the  long  fimbriated  growths  float 
out  like  slender-leaved  aquatic  plants  in  deep  water ; 
and  when  removed  to  air,  collapse  and  form  a  soft 
mass  resembling  a  small  strawberry.  Usually  one 
only  is  found  in  a  bladder  ;  sometimes  there  are  two 
or  three,  and  sometimes  minute  growths  of  the  same 
kind  may  be  found  affecting,  more  or  less,  the 
lining  membrane  of  the  cavity  (see  figs.  9  and  10  ; 
also  fig.  1  at  p.  11).  The  microscopic  structure, 
which  has  been  often  well  described,^  may  be  given 

^  Examples  of  these  have  been  presented  to  the  Pathological  Society 
of  London  by  several  observers  ;  among  them  by  myself  as  early  as 
1856.  Vide  vol.  v.  p.  200,  and  vol.  vi.  pp.  213-4,  both  relating  to  the 
same  case.  Another,  vol.  vii.  pp.  256-7.  Also  vol.  viii.  pp.  262-4  ; 
vol.  xi.  pp.  153-5  ;  vol.  xviii.  pp.  176-8  ;  vol.  xxi.  pp.  239-44  and 
265-6  ;  vol.  xxxiii.  p.  220  ;  vol.  xxxiv.  pp.  157-60. 


58         ON  TUMOUES  OE  THE  BLADDEK 


Fig.  9. — Fimbriated  papilloma   ('  villous '),  arising  from  a  single 
peduncle.     From  Museum  of  University  College,  No.  1471  A. 


Fig.   10.— Fimbriated  papilloma  ('villous')-      From  Museum   of 
Eoyal  College  of  Surgeons,  No.  2005. 

briefly  as  follows  :    '  Each  of  these  delicate   papilla3 
or    "  villi  "    consists  of  a  connective-tissue  ground- 


PLATE   II. 


:.#f^  ^m^ 


/ 


^'r^ 


o; 


/^         -> 


^O- 


7         ff^ 


m 


^^, 


^^/€^~3,-'^,cCl'tf        /'- 


)i'^y 


FlMBRIAXKP      rAFILLOMA,     PHOIVING     TWO      07       THE      SLEXDER      PAriLLOMATOT'S 
PTiOCKSSKS    OB,   lSO    CALMP,   '  ViLLI  '  ;     X  160       (FJROM   CAi^K  15   OF  TMF.  TABLE.") 


FIBRO-PAPILLOMA  59. 

work,  covered  by  layers  of  columnar  cells,  resting 
on  a  fine  basilar  membrane,  and  exactly  resembling 
those  of  the  normal  bladder.  In  the  deeper  part 
there  are  bands  of  non-striped  muscle.  These 
bands  do  not  run  into  the  papillte,  only  two  or 
three  isolated  fibres  enter  their  bases.  The  growth 
is  well  supplied  with  blood-vessels ;  capillaries 
running  up  and  into  the  villi,  and  branching 
directly  under  the  basement  membrane.  They  are 
large,  and  have  very  delicate  walls.'  (Dr.  H.  Gibbes.) 
The  case  of  T.  H.  B.,  aged  40,  case  No.  15,  is 
the  best  example  of  this  in  the  series  :  see  Plate  II., 
in  which  drawing,  as  in  those  which  follow,  the 
structures  have  been  faithfully  and  very  admirably 
represented. 

2.  Fihro- Papilloma. — I  prefer  this  term  to  that 
of  '  Ordinary  papilloma '  as  first  suggested,  because 
it  more  correctly  indicates  the  difference  between 
the  structure  now  in  question  and  that  described  as 
'  fimbriated.'  Thus  in  '  fibro-papilloma,'  the  papillary 
processes,  although  present  in  more  or  less  abundance, 
do  not  constitute  the  chief  part  of  the  structure,  which 
is  accordingly  more  solid,  consisting  of  the  consti- 
tuents, unstriped  muscle,  and  connective-tissue  fibres 
of  the  submucous  tissues  of  the  vesical  coats.  The 
papillae  are  sometimes  shorter,  less  developed  than  the 
'  fimbriated  '  processes  of  the  previous  division.  The 
microscopical  report  of  the  solid  part  or  groundwork 


60         ON  TUMOURS  OF  THE  BLADDER 

of  the  tumour  in  a  typical  case  is  as  follows  :  '  Here 
there  is  a  distinct  outgrowth  from  the  wall  of  the 
bladder,  of  trabeculse  composed  for  the  most  part 
of  non- striped  muscle- tissue.  From  these  trabeculas 
arise  secondary  trabeculse,  into  which  the  non-  striped 
muscle-tissue  is  continued  in  varying  amount,  accord- 
ing to  their  size.  The  growth  is  covered  with  layers 
of  columnar  epithelial  cells,  exactly  similar  to  those 
of  the  normal  bladder.'  Of  this  class  the  case  of  Dr. 
MacC,  No.  4,  is  one  of  the  best  examples.  See  Plates 
III  and  lY. 

It  may  be  remarked  here  that  the  mere  presence 
of  papillee  on  a  tumour,  whether  met  with  in  the 
simple  form  which  has  been  just  referred  to,  or  when 
assuming  the  long  fimbriated  form  previously  de- 
scribed, does  not  serve  in  any  way  to  identify  or 
characterise  a  growth,  since  such  papillae  may  be  met 
with  springing  from  the  surface  of  heteroplastic 
growths,  as  epithelioma  and  cancer. 

3.  Tumours  of  a  Transitional  Type, — The  third 
type  above  referred  to,  although  related  with  the 
preceding,  inasmuch  as  the  basic  structures  are 
still  homologous  with  those  of  the  bladder,  appears 
to  be  best  indicated  by  using  the  term  '  transitional ' 
to  describe  it,  as  perhaps  occupying  a  place  be- 
tween papilloma  and  a  formation  of  malignant  type, 
sarcoma.  Thus  there  is  not  only  a  peculiarity  in  the 
arrangement  of  the  basic  fibres,  but  the  presence  of 


PLATE    III. 


K. 


I'MlKll-rAriLLO.MA  :   UNDEU  A  LoW    PoWEll  (X  80)   TO    SHOW   GEXEiiAL  ^r.\^..\\• 
MEXT  01''  STUUCTUJiE.      (1?E0M  CASE  NO.  i  OF  THE  TABLIS.') 


PLATE   TY. 


■>isf»('  J* 


V&f 


%K. 


-i  "^^jrVi^tj 


FiBEo-PAriLLOJiA :  rxnEK  Hien  Powek  (x340)  showing  a  Capillary 
Vessel  axd  a  tew  No'-stkiped  Muscle-Fibres.  (Fbom  Case  No.  4  of 
THE  Table.) 


PLATE   Y. 


iS^. 


ii^-j 


■-Ci_::s 


.jr-S  -<, 


//• 


.-■^ 


ExiMPLi:  OP  THE  '  Traxsitioxal  '  Type  of  Tu.moue  :  showing  the  Grouxd- 

SUBSTANCE    INFILTRATED    WITH    VABIOUSLY-SHAPED    CELLS.;     AND    NUMEROUS 
BLOOD-VESSELS  RUXXIN(J  to  THE  SURFACE  :  OXE  HAS  GIVEN  WAY,  AND  EFFUSED 

Blood  is  well  shown  at  the  highest  point  :   x  ICO.    (From  Cask  Ko.  1-' 
ov  THE  Table.) 


OF    A    TRANSITIONAL    TYPE  61 

certain  cells  foreign  to  the  structure  itself  is  observed 
— a  fact  of  importance. 

Dr.  Heneage  Gibbes  describes  these  tumours  as 
'  characterised  by  a  dense  fibrous  groundwork  of  very 
irregular  growth  ;  and  by  the  presence  in  this  ground- 
work of  variously  shaped  cells,  generally  arranged  in 
definite  groups.  In  some  they  are  small  round  cells, 
in  others  large  irregularly  shaped  cells  with  nuclei. 
In  some  of  these  tumours  there  are  in  parts  short, 
thick  papilla  :  in  other  places  there  are  no  papilla3, 
but  in  all  cases  the  surface  is  covered  by  colum- 
nar epithelial  cells,  resembling  those  of  the  normal 
bladder.  The  one  feature  which  differentiates  them 
from  the  two  preceding  forms  is  the  arrangement  of 
the  ground  substance,  and  the  presence  in  it  of  the 
irregularly  shaped  cells,  which  do  not  belong  to 
normal  tissue  on  the  one  hand,  or  to  distinct  new 
growth  on  the  other.'  These  characters  excite  sus- 
picion as  to  the  issue  of  the  growth.  The  cases  of 
C.  C.  S.,  No.  12,  and  T.  S.,  No.  16,  are  examples  of 
this  group  :  see  Plate  Y.,  which  is  faithfully  drawn 
from  Case  12. 

The  second  category  of  growths,  the  characteristic 
of  which  is  heteroplastic  structure,  is  illustrated  in 
the  bladder  by  epithelioma,  and  perhaps,  but  if  so, 
certainly  in  rare  instances,  by  the  sarcomata  :  between 
which  latter  and  the  papillomata  a  relation  has  been 
suggested  in  the  last-noticed  growth  of  the  previous 


62  ON  TUMOURS  OF  THE  BLADDER 

category,  through  the  presence  of  certain  cells  above 
described. 

One  example  of  epithelioma  was  met  with  in  my 
series,  namely  Case  6.  It  will  be  unnecessary  to  enter 
on  any  description  of  this  familiar  product,  but  a 
microscopic  section  of  that  tumour  is  seen,  Plate  YI. 
The  existence  of  true  sarcoma  of  the  bladder  has  been 
affirmed,^  but  not  on  the  observation  of  fresh  speci- 
mens. The  presence  of  leucocytes,  or  of  other  cells, 
both  round  and  spindleshaped,  liable  to  be  found  in 
abundance  after  inflammatory  action  in  the  growth, 
or  as  seen  in  the  transitional  form  described,  has 
perhaps  led  some  observers  to  pronounce  such  struc- 
tures to  be  sarcoma.  Before  long  it  is  not  improbable 
that  some  unquestionable  example  will  be  met  with 
and  identified. 

Scirrhus  undoubtedly  occurs  as  a  deposit  in  the 
walls  of  the  bladder,  and  usually  affects  the  base  and 
sides  sufficiently  to  admit  of  identification  by  rectal 
examination.  The  hard,  unyielding,  irregular,  knotty 
outline  presented  there  to  the  finger  is  so  charac- 
teristic as  to  make  its  presence  easily  recognised. 

Cancer  of  an  encephaloid  type  is  sometimes  met 
with,  but  it  is  difficult  at  present  to  say  how  often  it 
affects  the  adult  bladder  ;  it  is  probably  not  common 
in  that  situation.  It  is  interesting  to  observe  that 
there  is  one  preserved  example  of  melanotic  growth, 

1  Path,  Trans.,  vol.  xxxiv.  p.  157. 


PLATE    Yi. 


/ 


'# 


m 


\ 

1  V 


,1 


\? 


« •  .     '  .liifs 


m^' 


:3 


Epithelioma  :  showixg  Ingrowth  of  Epithelium  axd  a  '  Nest  '  ix  'i'hk  Cextiik 
OF  the  Section- :   x  160.     ("From  Case  No.  6  op  the  Table.) 


OE    A    CANCEROUS    NATURE 


G3 


a  very  small  one,  affecting  the  bladder.  It  is  in  the 
Museum  of  Guy's  Hospital,  and  was  found  at  the 
autopsy  of  a  man  aged  thirty-two,  who  had  been  a 
patient  with  melanotic  disease  of  the  eyeball,  and 
with  similar  deposits  in  various  other  parts  of  the 
body.     It  is  represented  at  fig.  11. 


Fig.  11. — Small  melanotic  tumour  of  the  bladder.     Guy's  Museum, 
No.  210^2°. 

Finally,  that  rare  product,  dermoid  tumour,  is 
occasionally  found  in  the  bladder.  The  contents  of 
dermoid  cysts,  it  is  well  known,  are  sometimes  ex- 
pelled, probably  from  an  ovarian  source,  through  the 
urinary  passages.  But  in  one  case,  which  occurred 
in  the  practice  of  my  friend  Mr.  T.  Bryant,  and 
which  I  had  the  pleasure  of  seeing  with  him,  the 
locality  of  a  dermoid  tumour  was  undoubtedly  vesical. 
It  occurred  in  a  married  lady,  aged  30,  whose  first 
symptoms  were  those  of  cystitis,  with  the  appearance 
in  the  urine  of  long  hairs  coated  with  phosphates, 
considerable  quantities  of  which  were  from  time  to 


64 


ON  TUMOUES  OF  THE  BLADDEE 


time  removed  from  tlie  bladder.  Subsequently  digital 
exploration  was  made,  a  pedunculated  tumour  dis- 
covered, and  completely  removed  in  two  operations. 
It  was  composed  of  a  tbick  layer  of  true  skin,  witb 
mucb  fibrous  matter,  interspersed  witb  sebaceous 
glands  and  bair  follicles.  Altogetber  it  much  re- 
sembled in  form  and  size  an  ordinary,  ratber  large 
button  musbroom.  Tbe  patient  is  now  absolutely 
free  from  all  symptoms.  I  am  indebted  to  Mr. 
Bryant  for  tbe  accompanying  drawings  illustrating 
tbe  nature  of  this  formation  (figs.  12  and  13). 


■o.y^ 


Fig.  12. — Dermoid  growth  removed  from  the  bladder,  with  hairs 
(A)  covered  with  phosphatic  concretion.  B.  First  part  re- 
moved. C.  Pedicle  with  ligature.  D.  Growth  and  pedicle 
finally  removed. 

It  may  be  now  fairly  inferred  tbat  tbe  common- 
est species  of  tumour  affecting  tbe  adult  bladder  are 


DERMOID    TUMOUKS 


65 


papilloma,  occurring  in  two  forms — the  fimbriated  in 
tufts  of  elongated  papillas,   and  the  fibro-papilloma, 


Section 


-J  Muscular        O^^^^^^fc 


Fig.  13. — Microscopical  appearance  of  a  section  of  the  skin 
covering  the  dermoid  tumour. 

more  solid,  largely  composed  of  the  ordinary  sub- 
mucous tissues  forming  the  vesical  coats — all  homoeo- 
plastic  in  character.  A  third  product,  more  or  less 
resembling  the  latter  in  its  fibrous  constituents,  but 
exhibiting  the  presence  of  cells,  doubtful  in  character, 
sometimes  perhaps  due  merely  to  inflammatory  action^ 
while  it  excites  suspicion  as  to  its  tendency,  cannot 
be  altogether  removed  from  the  homoeoplastic  group, 
and,  as  before  said,  is  provisionally  termed  '  transi- 
tional.'   The  papillomata  have  certainly  no  malignant 


66  ON  TUMOURS  OE  THE  BLADDER 

tendencies,  but  their  disposition  to  increase  and  fill 
the  cavity  of  the  bladder,  and  thus  to  disintegrate  at 
their  periphery,  together  with  their  vascularity  and 
consequent  strong  disposition  to  bleed  largely,  render 
them  sooner  or  later  invariably  fatal. 

About  ten  or  eleven  cases  of  my  own  series 
are  certainly  papillomatous.  Collating  the  accounts 
given,  and  the  phenomena  manifested  by  these 
patients,  the  general  symptoms  may  be  described  as 
follows  : — 

Symptoms.  —  The  earliest  symptom  is  mostly 
haimorrhage.  It  is  observed  before  unduly  frequent 
micturition  is  complained  of  and  before  it  is  painful. 
On  the  other  hand,  in  most  of  the  cases  in  which 
the  tumour  was  of  the  malignant  type  or  approached 
thereto,  pain  and  frequency  of  passing  water  gener- 
ally preceded  the  appearance  of  blood,  sometimes  for 
a  considerable  period  of  time.  In  almost. all  cases 
symptoms  had  been  noted  during  at  least  three  years 
before  the  patient  applied  to  me  ;  in  some  as  much 
as  six  or  seven  years.  When  the  growth  consists 
chiefly  of  delicate  filiform  papillse,  the  bleeding  is 
more  continuous  and  free  than  in  '  fibro-papilloma,' 
or  in  the  '  transitional '  forms,  where  the  structure 
is  more  solid,  and  where  the  fimbriated  processes  may 
be  altogether  absent,  or  but  little  developed.  There 
appears  to  be  nothing  particularly  characteristic  in 
the  nature  of  the ,  haemorrhage,  excepting   the  one 


SYMPTOMS    AND    PHYSICAL    SIGNS  67 

important  circumstance,  always  to  be  inquired  for,  and 
which  ought,  if  possible,  to  be  observed  by  the  sur- 
geon himself;  namely,  that  in  the  act  of  micturition 
the  stream  may  sometimes  commence  without  any 
blood  stain,  or  with  only  a  slight  admixture,  and  end 
of  a  bright  red  colour  from  the  presence  of  much  fresh 
blood.  With  such  an  occurrence,  and  no  recent 
urethral  lesion  having  been  made,  the  source  of 
hsemorrhage  must  always  be  vesical.  Supposing  in 
such  circumstances  that  the  absence  of  stricture,  ordi- 
nary diseases  of  the  prostate,  calculus  of  the  bladder, 
and  cancer,  have  .been  ascertained  by  sounding  and 
by  rectal  examination,  it  remains  only  to  observe 
certain  products  which  the  urine  itself  may  contain. 

Physical  Signs. — I  should  first  say,  that  little 
positive  evidence  is  obtained  by  the  rectal  and  vesical 
examinations  just  referred  to,  in  relation  to  any  other 
growth  than  the  hard,  cancerous  deposits,  which  are 
usually  easy  enough  to  identify.  The  result  is 
generally  negative,  or  nearly  so,  when  a  growth  of 
the  papillomatous  or  of  the  allied  variety  is  present. 
The  only  positive  physical  sign  thus  attainable  which 
I  have  met  with,  and  this  in  a  few  cases  only,  has  been 
the  sense  of  slight  obstruction  to  the  free  movement 
of  the  sound  on  one  or  the  other  side  of  the  bladder, 
in  others  merely  '  a  soft  feel,'  as  I  have  termed  it 
in  my  notes,  as  if  one  were  moving  the  sound  in  a 
thicker  medium  than  urine,  and  without  so  defined  a 

F   2 


68         ON  TUMOURS  OF  THE  BLADDER 

limit  as  is  presented  by  the  healthy  vesical  walls. 
Then,  when  examining  by  rectum,  a  soft  rounded 
fulness  is  sometimes  to  be  felt  when  the  finger  can  be 
passed  beyond  the  prostate  to  the  base  of  the  bladder, 
but  nothing  that  is  in  the  least  degree  definite  or  dis- 
tinct. 

I  have  made  a  practice  of  fully  examining  the 
bladder  with  a  sound,  and  the  rectum  by  means  of 
the  finger  while  the  patient  is  under  the  influence  of 
ether  on  the  operating  table,  prior  to  performing 
digital  exploration  ;  nevertheless,  such  are  the  con- 
clusions I  am  compelled  to  come  to  in  relation  to 
sounding  for  tumour. 

Examination  of  the  Urine. — This  process  is 
highly  important,  and  is  often  very  significant.  Its 
object  is  to  obtain  disintegrated  portions  of  the  tumour 
if  present,  and  to  identify  their  structure  under  the 
microscope.  It  may  be  necessary  to  examine  several 
specimens  in  order  to  obtain  indubitable  evidence  on 
this  point.  An  excellent  way  of  obtaining  such 
specimens  is  to  wash  out  the  bladder  freely  with 
warm  water.  It  rarely  happens  that  this  process  fails 
to  detach  fragments  sufiicient  for  our  purpose  if  there 
is  a  fimbriated  growth  in  the  interior.  But  I  have 
recently  adopted,  after  failure  by  simple  washing,  the 
use  of  an  evacuating  catheter  of  small  size,  connected 
with  the  aspirator  employed  in  lithotrity,  and  by  this 
means  have  easily  obtained    specimens  which  were 


EXAMINATION    OF    THE    URINE    FOR  69 

complete  evidence  of  the  presence  of  a  growth.  This 
occurred  in  my  last  case,  No.  20. 

There  is  still  another  method  which,  when  a  fim- 
briated growth  is  present,  will  secure  a  specimen,  and 
will,  moreover,  sometimes  identify  the  presence  of  a 
salient  tumour.  It  consists  in  carefully  exploring 
the  bladder  with  a  small  flat-bladed  lithotrite.  I  dis- 
covered my  first  tumour  thus  ;  it  was  coated  with 
phosphates,  and  I  thought  it  might  be  a  partially 
sacculated  calculus,  as  I  could  seize  but  could  not 
move  it.  I  have  been  able  to  detach  small  portions 
of  a  growth  thus,  a  little  haemorrhage  necessarily 
resulting. 

Supposing,  however,  that  some  fragments  have 
been  washed  out,  these  should  be  placed  under  a 
:|-inch  object-glass,  when  the  following  elements 
may  be  sought.  First,  a  portion  of  a  slender  papilla, 
or  so-called  '  villus,'  sufiiciently  complete  for  identi- 
fication, may  be  met  with  ;  the  arrangement  of  colum- 
nar epithelium,  at  right  angles  to  a  central  axis,  and 
radiating  round  the  terminal  point,  and  presenting  a 
structure  which  is  unquestionable  proof  of  the  exist- 
ence of  such  a  growth  in  the  bladder.  On  two  occa- 
sions I  have  decided  to  operate  on  the  strength  of  this 
evidence. 

Secondly,  the  appearance  to  the  naked  eye  of  small, 
slightly  translucent,  semigelatinous  fragments  in  the 
urine  are,  of  course,  very  significant.    Under  the  power 


70         ON  TUMOURS  OF  THE  BLADDER 

named,  these  mostly  appear  to  be  made  up  of  spindle- 
shaped  nucleated  cells,  some  comparatively  short  and 
broad,  others  elongated,  and  some  nearly  acquiring  the 
character  of  a  short  fibre.  These  fragments  have  been 
present  in  several  cases  in  which  tumour  has  been 
subsequently  found  ;  a  fact  which,  in  each  instance,  is 
noted  in  the  Table  of  Cases.  In  two  or  three  instances 
I  have  examined  the  urine  day  after  day,  and  found 
no  characteristic  structure,  but  this  was  before  I 
sought,  as  I  now  invariably  do,  by  purposely  washing 
out  the  bladder.  In  one  or  two  others  I  have  found 
great  numbers  of  cells  like  young  pavement  epithe- 
lium, but  these  are  not  sufficiently  characteristic  to 
offer  any  indication  available  for  diagnosis. 


71 


CHAPTER  IV. 

OPERATIONS  FOR  THE  REMOVAL  OF  TUMOUR  AND 
THEIR  RESULTS — CASES  AND  TABLE. 

Treatment  —  Styptics  —  Injections  —  Operation    for    their    removal — 
Results — Cases. 

Treatment. — Supposing  we  have  arrived  at  the  con- 
clusion that  the  bleeding  is  certainly  vesical,  and  that 
in  all  probability  it  arises  from  the  presence  of  an 
intravesical  growth  respecting  which  there  is  no  evi- 
dence that  it  is  cancerous  in  its  nature  : — are  there 
any  means  to  be  employed  for  checking  the  growth, 
or  even  for  destroying  it,  without  having  recourse  to 
a  surgical  operation  involving  the  use  of  the  knife? 
Are  there  any  means  by  which  haemorrhage  may  be 
subdued  or  restrained  in  cases  considered  temporarily 
unfit  for  operation  through  exhaustion,  &c.,  or  for 
cases  in  which  operation  is  only  partially  successful  in 
removing  the  tumour,  and  a  portion  is  inevitably  left 
behind  ;  or  for  those  cases  of  malignant  tumour  which 
are  not  amenable  to  any  attempt  to  remove  them,  and 
are  therefore  only  susceptible  of  palliative  treatment? 
I  would  reply  that,  in  my  experience,  I  do  not 
know  one  of  the  so-called  internal  styptic  remedies 


72         ON  TUMOURS  OF  THE  BLADDEE 

which  is  of  any  service  in  vesical  haemorrhage  from 
any  form  of  tumour.  It  is  exceedingly  difficult  to 
prove  a  favourable  result  on  the  trial  of  any  one 
of  these  agents.  An  attack  of  vesical  ha3morrhage 
naturally  runs  a  short  course  provided  the  patient 
ceases  his  usual  active  habits.  It  is  in  connection 
with  this  influential  treatment — viz.  rest  and  the 
recumbent  position — that  styptics  are  given  ;  and 
when  the  haemorrhage  stops,  as  it  has  a  natural 
tendency  to  do,  the  drug  swallowed  at  the  time 
obtains  the  credit  of  a  power  which  almost  certainly 
does  not  belong  to  it. 

I  have  much  more  confidence  in  astringent  injec- 
tions thrown  into  the  bladder  with  great  gentleness, 
and  through  a  small  soft  catheter.  The  two  which 
I  have  used,  and  with  some  frequency,  for  cases  in 
which  operation  is  not  at  present  decided  on,  and 
especially  for  those  in  which  the  tumour  has  been 
only  partially  removed,  are  perchloride  of  iron  and 
nitrate  of  silver.  These  latter  cases  have  been  far 
more  improved  after  incomplete  operative  procedure 
than  I  could  have  anticipated,  and  their  recurring 
haemorrhages  have  been  readily  controlled  by  these 
agents,  the  iron  being,  perhaps — certainly  in  two 
of  these  cases — more  efficient  than  the  other.  The 
strength  employed  has  been  from  20  to  60  minims  of 
the  tincture  of  the  perchloride  of  iron  in  4  ounces  of 
cold  water  ;  to  be  used  daily  once  or  twice,  accord- 


TREATMENT    BY    INJECTIONS  73 

ing  to  circumstances.  Of  the  nitrate  of  silver,  from 
gr.  i.  to  gr.  vi.  in  4  omices  of  water  ;  the  stronger 
solutions  being  rarely  tolerated  or  necessary. 

In  regard  of  malignant  disease  above  alluded  to,  I 
may  in  this  place  briefly  but  emphatically  state  that 
if  the  physical  characters  and  symptoms,  especially 
the  former,  indicate  the  presence  of  a  growth  of  this 
nature,  any  operative  proceedings  for  its  removal 
must  be  not  merely  futile  and  imperfect,  but  ex- 
tremely dangerous,  and  ought  not  to  be  undertaken. 
It  does  not  follow,  however,  that  in  such,  cases  the 
draining  of  the  bladder  by  a  perineal  opening  may 
not,  in  certain  circumstances,  be  a  useful  proceeding 
to  relieve  suffering  or  prolong  life,  &c. 

Lastly,  I  do  not  propose  to  do  more  than  name 
here  the  great  importance  of  careful  attention  to  the 
digestion  and  state  of  the  bowels,  in  all  cases  of 
haemorrhage  from  intrapelvic  sources,  but  shall  re- 
turn at  once  to  consider  the  only  means  of  affording 
permanent  relief  to  the  subject  of  vesical  tumour, 
namely,  the  operation  for  its  removal. 

Operation. — We  now  suppose  that  digital  ex- 
ploration has  been  made  by  external  urethrotomy, 
and  that  the  steps  of  the  proceeding  have  been 
followed,  as  described  in  the  second  chapter,  and 
further,  that  the  operator,  on  introducing  his  left 
index  finger,  at  once  encountered  a  growth  of  some 
kind.     He  should  first  deliberately  spend  some  two, 


74         ON  TUMOURS  or  THE  BLADDER 

three,  or  four  minuteSj  if  necessary,  in  ascertaining 
its  size,  situation,  and  general  outline. 

Pressing  the  abdomen  firmly  with  his  right  hand 
into  the  pelvic  basin,  he  soon  ascertains  whether  the 
tumour  be  attached  to  the  wall  of  the  bladder  by  a 
narrowish  pedicle,  or  whether  it  is  rather  an  out- 
growth which  springs  from  a  considerable  area  of  the 
coats,  and  is  inseparable  from  them.  He  traces  the 
surface,  which  may  be  broadly  mamillated,  one  or 
many  lobed,  or  simply  polypoid,  firm  in  contour,  or 
soft  and  fleecy.  Lastly  he  observes  whether  the 
whole  is  dense,  compact,  and  immovable,  or  soft, 
more  or  less  floating,  and  perhaps  fragile.  It  is  im- 
portant to  have  a  distinct  idea  of  the  situation  of  the 
tumour,  as  to  whether  it  lies  more  to  the  operator's 
right  or  left,  which  is  at  once  apparent  in  most 
instances  ;  then,  whether  it  belongs  more  to  the  side 
or  to  the  floor  of  the  bladder,  or  whether  it  springs 
from  the  opposite  surface  farthest  from  the  meatus, 
or  from  the  upper  aspect  of  the  cavity.  The  mind 
soon  forms  a  distinct  image  of  the  body  to  be  dealt 
with,  and  simultaneously  arrives  at  a  judgment  as 
to  whether  it  be  possible  to  remove  it  entirely  or 
partially,  and  if  the  latter,  whether  a  sufficient  portion 
can  be  safely  taken  away  to  warrant  further  surgical 
interference.  If  the  tumour  be  polypoid  in  form, 
with  a  distinct  pedicle,  narrow,  or  even  wide,  there 
can  be  no  doubt  as  to  the  propriety  of  operating. 


THE    OPERATION   BY    EXTERNAL   URETHROTOMY       75 

But  if  the  growth  admits  of  considerable  portions 
being  removed  without  injuring  the  substance  of  the 
vesical  coats,  which  -should  be  approached  with  great 
caution,  then,  also,  my  opinion  is  that  such  portions 
should  be  attacked,  under  the  conditions  hereafter  to 
be  named.  When,  on  the  other  hand,  the  substance 
is  hard,  and  exhibits  no  marked  prominence  of  con- 
tour, characters  usually  found  to  be  associated,  no 
such  attempt  should  be  made  ;  a  small  portion  may 
be  easily  removed  for  microscopic  examination,  and 
that  should  be  done. 

But  now  comes  an  important  consideration  which 
should  be  carefully  disposed  of  before  any  interference 
with  the  tumour  takes  place  from  the  perineal  opening. 

When  the  survey  of  the  vesical  cavity  has  been 
completed,  the  operator  has  to  determine  the  follow- 
ing question :  Am  I  capable  of  completing  my  design 
of  removing  the  tumour  before  me  wholly  or  parti- 
ally, as  the  case  may  be,  through  the  incision  made, 
or  should  I  do  so  more  efficiently  through  a  supra- 
pubic opening  ?  For  it  may  be  taken  for  granted 
that  a  case  may  occasionally  present  itself  in  which 
the  latter  course  may  appear  to  be  preferable,  and 
if  so  there  is  no  reason  whatever  for  not  selecting 
it.  The  perineal  incision  made  will  not  add  to 
the  risks  of  the  case,  and  it  has  afforded  that  most 
important  element,  the  means  of  obtaining  an  exact 
diagnosis. 


76  ON  TUMOURS  OF  THE  BLADDER 

Now  I  may  here  say  that  my  proposal  to  remove 
vesical  tumours  by  perineal  urethrotomy  has  met  with 
a  direct  challenge  in  Paris  from  my  friend  Professor 
Guyon  and  his  school,  who  say  that  the  suprapubic 
operation  should  be  invariably  employed  for  the  pur- 
pose, and  the  perineal  operation  never.  I  cannot 
refrain  from  suggesting  that  the  emphasis  with  which 
this  doctrine  is  just  now  enunciated  by  some,  would 
be  more  authoritative  had  the  writers  ever  tested  the 
method  I  have  now  so  often  practised.  There  can,  I 
suppose,  be  no  hesitation  in  anyone's  mind  that  the 
high  operation  is  a  much  more  formidable  and 
hazardous  proceeding  than  the  simple  boutonniere. 
Why,  then,  should  the  former  be  practised  in  any 
case  until  absolute  certainty  is  attained,  not  only 
that  tumour  is  present,  but  also  that  it  is  remov- 
able by  operation  ?  No  doubt  that  in  a  consider- 
able proportion  of  suspected  cases,  the  presence  of 
tumour  may  be  regarded  as  strongly  probable  ;  but 
in  very  few  can  it  be  stated  with  certainty  until 
the  finger  has  entered  the  bladder.  In  no  single 
case  can  the  surgeon  ascertain  whether  or  no  the 
tumour  in  question  is  separable  from  the  bladder 
until  the  cavity  has  been  opened  and  the  physical 
conditions  examined.  Well,  all  these  facts— first, 
the  fact  of  the  presence  of  tumour;  secondly,  its 
form  and  size  ;  thirdly,  the  nature  of  its  connections 
with  the  vesical  structures— all  the  data  necessary 


PERINEAL    PREFERABLE    TO    HIGH    OPERATION       77 

for  determining  the  question  of  operation  can  be 
attained  by  a  slight  urethral  incision  which  involves 
no  risk.  What  imprudence,  then,  can  be  greater  than 
that  of  performing  the  high  operation  with  all  its 
admitted  risks  while  the  operator  does  not  know  for 
certain  that  a  tumour  is  present  ;  and  while  he  knows 
that  if  he  does  find  one  the  numerical  chances  are  even 
that  the  tumour,  although  thus  completely  approached 
and  laid  bare,  cannot  be  entirely  removed  without 
inflicting  fatal  injury  on  the  patient ;  since  one-half 
the  cases  are  not  completely  removable. 

Further,  I  declare  that  while  the  boutonniere 
enables  the  surgeon  to  ascertain  all  the  facts  which  it 
is  so  necessary  to  obtain  before  operating,  it  also 
enables  him  to  remove  the  tumour  without  difficulty, 
when  it  is  polypoid  in  form,  and  therefore  capable  of 
being  removed  with  a  fair  amount  of  ease  and  safety. 
If  however  he  believes — and  he  is  then  in  a  position 
to  determine  the  question — that  he  can  attain  a  better 
result  in  any  particular  case  by  the  high  operation, 
there  is  nothing  whatever  to  prevent  his  performing 
it.  In  one,  or  at  most  two,  of  my  twenty  cases, 
in  two  of  the  early  ones  perhaps  I  might  have  so 
operated  with  advantage.  I  should  probably  do  so 
now  on  again  encountering  similar  conditions,  but  in 
all  the  remaining  cases  the  risk  to  the  jDatient  would 
have  been  greatly  increased  by  performing  the  high 
operation,  and  I  should  have  acquired  no  facility  for 


78        ON  TUMOURS  OF  THE  BLADDER 

removing  his  tumour  beyond  that  which  external 
urethrotomy  afforded  me.  On  the  other  hand,  when  a 
tumour  is  discovered  which  it  is  impossible  to  remove, 
I  have  the  satisfaction  of  knowing  that,  at  all  events, 
nothing  has  been  done  to  endanger  the  patient's  life 
by  the  simple  operation  which  has  been  performed. 

We  shall  now  consider  the  means  which  it  is 
desirable  to  employ  m  order  to  remove  the  tumour, 
when,  having  examined  it  fully,  we  have  decided 
to  make  an  attempt  through  the  perineal  opening. 
First,  if  we  have  the  good  fortune  to  encounter  a 
single  growth,  polypoid  in  form  (see  diagrams,  in 
the  Table  of  Cases,  Nos.  1  and  also  13  and  15),  and 
therefore  with  a  pedicle  of  no  great  width,  there 
need  be  no  hesitation  whatever  in  introducing  a 
pair  of  forceps  into  the  cavity  of  the  bladder,  and 
employing  them  there  without  any  aid  from  the 
operator's  finger.  The  forceps  to  be  used  for  this 
purpose  are  to  have  rather  wide  and  serrated  margins 
where  the  blades  meet,  so  as  to  crush,  but  without 
any  power  to  cut  the  tissues  seized.  These  forceps 
should  be  provided  in  different  forms.  The  first, 
or  simplest  pattern,  should  be  straight,  resembling 
an  ordinary  lithotomy  forceps  (fig.  14).  Others 
should  be  curved  for  seizing  tumours  which  are 
situated  laterally  and  near  to  the  neck  of  the  bladder, 
in  which  last-named  position  the  straight  forceps 
are  powerless  to  grasp  the  tumour  (figs.  15  and  17). 


FORCEPS    USED   FOR    REMOVING    TUMOURS  79 


Fig.  14.  —Straight  forceps. 


Fig.  15. —  Slender,  laterally  curved  forceps,  for  removing  a  growth 
close  to  the  neck  of  the  bladder 


Fig.  16. — The  same  forceps  looked  at  from  the  front,  so  as  not  to 
show  the  curve. 


Fig.  17. — Curved  forceps  for  tumours  occupying  the  sides  of  the 
bladder. 


Fig.  18. — The  same  forceps  looked  at  from  the  front. 


80        ON  TUMOURS  or  THE  BLADDER 

A  pair  of  each  pattern  should  have  cutting  edges 
for  exceptional  cases,  when,  for  example,  the  growth 
is  more  firm  and  solid  than  usual.  When  the 
blades  are  free  in  the  cavity  they  have  merely  to  be 
opened  easily  and  widely,  and  on  closing  them  it  is 
almost  certain  that  they  will  grasp  the  polypus  more 
or  less  completely.  The  proceeding  thus  advised  is 
more  likely  to  prove  successful  in  accomplishing  its 
object,  than  is  the  attempt  to  seize  a  stone  in  the 
bladder.  But  here  let  it  be  observed  that  no  supra- 
pubic pressure  should  be  made  during  this  act ; 
nothing  should  be  done  to  interfere  with  the  natural 
contour  of  the  bladder.  The  operator,  by  light  and 
easy  movements  of  the  forceps  in  varied  directions, 
ascertains  that  he  has  the  growth  within  their  grasp. 
My  advice  is  that,  above  all  things,  he  is  not  now  to 
pull  forcibly,  but  that  he  is  to  press  firmly  the  blades 
together,  biting  or  chewing  a  little,  if  I  may  use  the 
terms,  with  the  extremities  of  the  blades,  without 
changing  the  original  situation  of  the  bite  or  grasp. 
Then  a  little  twisting  movement  may  help  to  dis- 
engage the  mass,  which  if  accomplished,  the  forceps 
will  be  felt  free,  and  may  be  withdrawn  with  their 
contents  ;  after  which  the  finger  enters  to  feel  what 
remains,  and  what  more  must  be  done  in  order  to 
complete  the  removal.  Let  me  remark,  whenever  the 
forceps  has  removed  a  portion,  however  small,  the  in- 
strument should  never  be  re-introduced  until  the  finger 


OTHER  INSTRUMENTS  TO  REMOVE  TUMOUR 


81 


has  again  examined  the  interior,  and  enabled  the  ope- 
rator to  form  a  fresh  estimate  of  the  portion  remain- 
ing, if  any,  to  be  removed.  But,  supposing  that  the 
tumour  has  not  been  separated  by  the  moderate 
amount  of  forceps  action  described,  the  operator  may 
disengage  and  remove  them  ;  when  on  introducing 
the  finger  he  will  probably  find  the  part  so  nearly 


Fig-.  19. — Instrument  with  serrated  end  for  separating  by  rotatory- 
movement  a  portion  of  tumour  fixed  by  the  index  finger. 
Seen  in  profile,  one-third  natural  size.  The  end  is  shown  in 
two  positions  of  the  natural  size. 


Fig.  20. — Another  serrated  instrument,  curved  in  form. 

severed  that  the  actual  division  may  be  completed 
with  the  finger  nail ;  or  with  one  of  the  little  serrated 
instruments  which  I  have  designed  for  the  purpose, 
and  for  the  employment  of  which  there  is  ample  room 
through  the  urethral  wound,  by  the  side  of  the  index 
finger  (see  figs.  19,  20).  There  is  really  no  difficulty, 
nor  is  there  any  risk,  with  ordinary  care,  in  removing 

G 


82         ON  TUMOURS  OF  THE  BLADDER 

a  growth  or  two  of  pedunculated  form,  sufficiently 
near  to  the  walls  of  the  bladder  to  render  the  opera- 
tion a  permanently  successful  one.  I  suppose  that 
the  ultimate  result  of  dividiiig  the  pedicle  of  a  tumour 
in  the  manner  described  is  such  a  cicatrisation  of 
the  wound  as  to  prevent  the  recurrence  of  outgrowth 
from  that  spot  hereafter. 

But  other  means  may  be  used  according  to  the 
judgment  of  the  surgeon.  A  very  small  ecraseur, 
with  violin-string  ligature,  may  be  manipulated  by 
the  side  of  the  index  finger,  and  used  in  polypoid 
forms  of  tumour.  In  the  cases  of  women,  such  a 
tumour  may  sometimes  be  slowly  and  carefully 
brought  into  view  by  traction  on  the  forceps,  and 
then  the  pedicle  may  be  ligatured.  I  have  succeeded 
in  doing  this  is  one  case  ;  so  has  Mr.  Bryant.  In 
another  I  drew  a  polypoid  mass  within  view,  and 
found  it  was  a  completely  encysted  calculus  ;  I  then 
opened  the  mass,  when  the  calculus  escaped. 

But  in  the  male  it  has  occasionally  happened  that 
the  tumour  can  be  drawn  through  the  wound,  as 
happened  with  Mr.  Davies  Colley,  and  also  with  Mr. 
Morris,  in  whose  case  the  growth  seemed  to  have 
been  extruded  by  natural  vesical  efforts  on  the  day 
after  operation  (having  been  left  untouched  on  the 
first),  and  was  then  removed,  the  patient  making  a 
good  recovery. 

But  when  the  growth  takes  a  more  complex  form 


PARTIAL    REMOVAL    IN    SOME    CASES  83 

— as  when  several  lobes  spring  from  a  wider  base, 
for  examples  see  diagrams  Nos.  4,  7,  13,  16,  in 
Table  of  Cases,  pp.  97-111 — the  forceps  must  be  de- 
pended upon  for  removing  them  by  repetitions  of  the 
same  process  which  is  employed  for  the  single  growth. 
But  when  the  base  is  wider  still  and  the  growth  is 
less  prominent,  as  that  represented  in  diagrams  Nos. 
5,  12,  17,  18,  19,  it  is  doubtful  whether  complete 
extirpation  is  possible  by  any  proceeding,  either 
through  a  perineal  or  through  a  suprapubic  opening. 
The  wide  base  involves  such  intimate  continuity 
of  tissue  between  the  coats  of  the  bladder  and  the 
structures  of  the  growth,  that  I  believe  separation 
to  be  mostly  impossible  ;  and  that  ablation  of  the 
promment  portions  of  the  growth,  when  feasible, 
should  be  undertaken  only  with  the  view  of  retard- 
ing its  progress,  but  with  no  prospect  of  effecting 
complete  separation  of  the  disease  from  the  body. 

These  portions  are  to  be  seized  and  destroyed, 
partly  by  removal  on  the  plan  just  described,  and 
partly  by  crushing,  and  thus  inducing  sphacelus  and 
sloughing  of  the  growth.  The  question  of  applying 
some  chemical  astringent  arises  in  such  cases,  and 
its  utility  may  be  regarded,  perhaps,  as  twofold.  A 
solution  of  the  perchloride  of  iron  may  tend  to  check 
the  haemorrhage,  which  is  almost  invariably  very 
free  for  a  few  hours  after  the  removal  of  wide -based 
growths,  and  it  may  partially   destroy  the  portion 

G  2 


84         ON  TUMOURS  OF  THE  BLADDER 

which  remains  after  the  forceps  have  done  their  work. 
For  this  purpose  I  have  contrived  a  straight  and  also 
a  curved  glass  syringe  containing  a  small  sponge, 
saturated  with  solution  ;  the  sponge  being  pressed 
by  the  piston  permits  the  escape  through  small 
perforations  at  the  extremity  of  from  30  to  60 
minims  of  the  solution,  at  the  precise  spot  where  it 
is  desired  to  make  the  application. 

There  is  one  circumstance  important  to  be  noted, 
especially  in  dealing  with  the  less  prominent  growths  ; 
and  that  is,  the  effect  of  strong  suprapubic  pressure 
made  by  an  assistant  in  relation  to  their  apparent 
situation,  and  their  mode  of  presentation  to  the  finger 
of  the  operator  engaged  in  exploring  the  bladder,  and 
in  estimating  their  size  and  form.  If  that  pressure  is 
considerable  it  forces  the  upper  wall  of  the  bladder 
into  its  own  cavity,  and  thus  gives  to  the  growths 
a  larger  contour  than  they  possess,  and  makes  them 
apparently  salient  to  a  much  greater  extent  than  they 
really  are.  Thus  an  eager  or  inexperienced  oper- 
ator, unaware  of  the  effect  of  strong  suprapubic 
pressure,  might  be  led  to  seize  the  mass  offered  to 
the  forceps,  through  the  influence  of  this  pressure, 
and  under  the  belief  that  it  was  a  large  growth,  he 
might  inflict  a  fatal  wound  by  crushing  a  double  fold 
of  the  coats  of  the  bladder,  and  so  making  an  opening 
in  the  peritoneum.  To  avoid  such  a  catastrophe  it 
is   only  necessary,  first,  to  decline   the  attempt  to 


RESULTS  OF  OPERATION  FOR  85 

destroy  any  growth  which  is  clearly  not  sufficiently 
salient  to  admit  of  complete  or  nearly  complete  re- 
moval ;  and,  secondly,  never  to  employ  the  forceps 
while  forcible  suprapubic  pressure  is  made  ;  at  least, 
no  more  pressure  than  is  desirable  just  to  steady  and 
support  the  bladder  and  the  parts  adjacent. 

Results. — We  have  now,  finally,  only  to  consider 
what  are  the  results  which  have  been  attained  by 
the  perineal  operation  in  relation  to  vesical  tumours. 

Of  the  twenty  cases  of  tumour,  two  were  in 
women  :  one  of  these  died  in  three  days  of  total  sup- 
pression of  urine  ;  autopsy  showing  advanced  disease 
of  kidneys  (one  contained  a  large  calculus),  and  that 
no  injury  was  inflicted  upon  the  bladder.  The  other 
is  now  in  excellent  health,  having  entirely  lost  her 
painful  symptoms  ;  observing  a  few  drops  of  blood, 
occasionally,  after  more  exercise  than  usual :  more 
than  two  years  have  elapsed  since  the  operation. 

Of  the  eighteen  male  cases,  five  died  within  three 
weeks  after  the  operation  ;  three  others  died  at  periods 
of  some  months  after,  two  of  them  from  malignant 
disease  developed  elsewhere.  The  other  nine  are 
living  ;  one  of  these,  from  whom  I  removed  a  tumour 
in  the  autumn  of  1882, 1  operated  on  again,  removing 
a  larger  growth  than  the  original  one  last  February, 
and  he  has  again  recovered.  In  four  cases  no  attempt 
was  made  to  remove  the  tumour,  it  being  manifestly 
impossible  to  do  so,  but  only  to  diminish  it  as  far  as 


86         ON  TUMOUES  or  THE  BLADDER 

practicable  with  safety  ;  all  these  recovered  well,  and 
are  rather  better  than  before.  Of  the  remaining  four, 
one  has  had  no  return  whatever,  four  years  having 
elapsed  since  the  operation  ;  a  second  has  slight  signs 
of  a  return,  one  year  and  a  quarter  since  operation, 
but  works  hard  for  his  living  at  64  years  of  age  ;  a 
third,  who,  like  the  last,  was  at  death's  door  from  loss 
of  blood  when  I  operated,  has  greatly  improved,  and 
is  actively  employed  ;  but  has  recently  shown  some 
disposition  to  bleed  after  exercise,  nearly  a  year 
since  operation.  The  fourth  was  greatly  improved, 
and  returned  to  the  active  life  for  which  he  was 
before  disqualified.  The  others  have  too  recently 
been  operated  on,  to  furnish  any  material  fact  to 
be  reported.  More  ample  details  are  furnished  in 
the  Table  of  Cases  drawn  up  and  accompanying 
this. 

1  may  thus  briefly  sum  up  the  record  of  the  nu- 
merous facts  related.  For  every  one  of  these  patients 
with  tumour,  in  the  natural  order  of  events,  one  result 
only  was  possible.  Left  without  surgical  aid,  death 
inevitably  awaited  each  :  a  fate  not  merely  certain, 
but  necessarily  involving  protracted  suffering. 

Whatever  surgery  can  accomplish  m  the  way  of 
saving  life  for  several  of  these  patients  is  obviously  so 
much  clear  gain.  I  am  therefore  satisfied  with  what 
has  been  achieved  for  the  first  twenty  cases  ;  having 
naturally  desired  greater  success  ;   but  I  have  reason 


RESULTS  OF  OPERATION  FOR  87 

to  expect  that  it  will  be  greater  in  the  next  twenty 
cases,  through  having  acquired  some  valuable  expe- 
rience which  I  have  thus  attempted,  so  far  as  this  is 
possible,  to  make  useful  to  others. 

We  may  certainly  reckon  on  ability  to  save  life  in 
a  few  instances,  such  as  are  recorded  here  ;  we  may 
also  often  prolong  valuable  life,  a  fact  illustrated  by 
several  of  the  cases  recorded  both  by  myself  and  by 
other  operators. 

There  is  still  another  result  which  ought  not  to 
be  overlooked.  Whatever  value  may  have  accrued 
to  a  few  patients  in  the  matter  of  saving  or  pro- 
longing life,  a  matter  which  is  wholly  incalculable, 
there  has  been  an  opportunity  afforded,  on  a  scale 
never  before  met  with,  for  careful  inquiry  into  the 
external  physical  characters  and  histological  elements 
of  vesical  growths.  This  research  has  been  system- 
atically pursued  ;  and  with  the  aid  of  valuable  co- 
operation already  referred  to,  I  have  been  able  to 
present  a  scheme  for  classifying  the  facts  obtained, 
which  I  trust  may  prove  to  be  a  contribution,  how- 
ever humble,  to  an  improved  acquaintance  with  this 
important  subject. 

I  append  five  of  the  cases  which  are  most  worthy 
to  be  reported  at  length,  partly  because  each  more  or 
less  illustrates  a  particular  type  of  growth,  together 
with  its  history  and    progress,   and   the    symptoms 


88         ON  TUMOURS  OF  THE  BLADDER 

associated  with  it,  and  partly  because  the  kind  of 
after-treatment  and  subsequent  history  are  to  some 
extent  indicated  also.  The  number  to  each  case 
corresponds  with  that  which  marks  its  place  in  the 
table  of  twenty  cases  which  follows  after. 

Case  1. — T.  R.,  set.  29.  Fibro  -  papilloma,  or  transi- 
tional (?). 

1880,  July  26.  He  first  consulted  me.  I  learned  that 
eight  years  previously  he  had  passed  '  a  piece  of  gravel  the 
size  of  a  pea.'  After  this  he  felt  nothing  unusual  until  three 
years  ago,  when  his  micturition  became  more  frequent,  and 
was  followed  by  pain  in  the  end  of  the  penis,  also  occasion- 
ally blood  appeared  in  the  urine,  especially  after  exercise. 

With  these  symptoms,  I  sounded  the  patient,  and  I 
found  a  small  calculus,  which  on  August  5  was  easily 
crushed  and  removed.     It  was  composed  of  oxalate  of  lime. 

Very  little  improvement  followed  the  operation :  the 
bladder  was  not  quite  emptied  by  the  natural  efforts ;  the 
gum  catheter  was  used  daily,  and  on  two  occasions  gave 
signs  of  the  presence  of  something  in  the  bladder,  which  a 
subsequent  exploration  of  the  lithotrite  did  not  discover. 
Such  results  were  unusual  and  somewhat  puzzling.  Being 
relieved,  he  resumed  his  employment,  and  was  occasionally 
seen  relative  to  the  still  existing  slight  symptoms,  which, 
however,  gradually  increased. 

On  October  5  I  examined  the  bladder,  and  removed  a 
quantity  of  phosphatic  deposit  with  the  lithotrite.  I  then 
seized  what  at  first  felt  like  calculus,  and  partially  crushed 
under  pressure ;  but  it  was  evidently  fixed,  giving  me  the 
impression  that  I  was  dealing  with  a  portion  of  stone  par- 
tially impacted,  and  that  the  remainder  would  be  beyond 
my  reach. 

1880,  Nov.  6.     I  made  exploration  after  median  incision 


SOME    CASES    OP    OPERATION    IN   DETAIL  89 

into  the  urethra  in  presence  of  Dr.  Seegen  of  Carlsbad,  Dr. 
Paggi  of  Florence,  and  Mr.  Ceeley  of  Aylesbinry.  Having 
introduced  my  finger  well  into  the  bladder,  and  pressure 
being  made  above  the  pubes,  I  soon  recognised  a  tumour, 
about  the  size  of  a  chestnut,  growing  apparently  from  the 
opposite  wall  or  fundus,  and  somewhat  to  the  patient's  left, 
coated  with  phosphatic  matter,  and  evidently  the  fixed  body 
I  had  formerly  seized  with  the  lithotrite  and  denuded  of  its 
sabulous  covering.  Taking  a  pair  of  small  forceps,  I  ad- 
justed them  to  a  full  and  firm  hold,  and  then  twisted  off  the 
mass  without  difficulty ;  a  small  piece  or  two  were  subse- 
quently withdrawn,  but  the  tumour  appeared  to  be  entirely 
removed,  and  very  Kttle  bleeding  followed.  He  had  no  bad 
symptoms,  made  a  rapid  recovery,  speedily  regained  good 
health,  never  having  had  any  return  of  symptoms  since  the 
operation,  now  nearly  four  years  ago.  He  is  now  in  perfect 
health,  June,  1884. 

Mr.  Stanley  Boyd,  formerly  Surgical  Registrar  of  Uni- 
versity College  Hospital,  examined  a  portion  of  the  tumour 
from  this  case,  and  his  report  thereon  is  as  follows  : — 

'  A  small  piece,  taken  from  the  surface  of  the  tumour, 
was  handed  to  me  for  examination.  It  was  thickly  encrusted 
with  phosphates,  and  beneath  these  the  surface  was  finely 
irregular.  On  section,  the  growth  was  firm  and  of  uniform 
consistence  ;  but  its  structure  could  only  be  guessed  at  as 
fibrous. 

'  Microscopically,  it  consisted  of  fine  bundles  of  fibrous 
tissue,  having  a  general  direction  vertical  to  the  surface. 
Small  round  cells  were  scattered  pretty  copiously  at  parts, 
especially  towards  the  free  surface,  but  there  was  no  regu- 
larity in  their  distribution.' 

It  might  perhaps  now  be  classed  as  an  example  of  '  fibro- 
papilloma.' 

Case  2. — Mrs.  F.,  aet.  30.     Fibro-papilloma. 

1882,  May  5.     I  first  saw  her  with  Dr.  Philson  of  Chel- 


90         ON  TUMOURS  OF  THE  BLADDER 

tenham,  and  learned  that  in  187*7  she  first  observed  blood 
in  the  urine,  but  had  no  pain. 

In  June,  1879,  severe  cystitis,  which  became  chronic. 
Throughout  1880-81  much  frequency  of  micturition,  but  no 
severe  attacks  ;  occasionally  blood  in  the  urine. 

1882,  February.  Much  bleeding.  In  March,  severe 
cystitis,  and  confined  to  her  room  since. 

May  9.  Dilated  the  urethra  under  ether,  detecting  a 
growth  (represented  by  the  diagram  in  the  Table)  at  the 
centre  of  opposite  aspect  of  bladder  behind  and  above  the 
trigone ;  and  removed  three  chief  portions  with  the  forceps. 
Bleeding  free  at  first,  subsiding  during  the  day.  A  catheter 
was  tied  in,  and  remained  forty-eight  hours,  She  made  a 
rapid  recovery,  and  left  town  holding  water  five  hours  at  the 
end  of  three  weeks. 

The  tumour  was  examined  by  Mr.  Stanley  Boyd.  See 
report  below. 

1883,  February.  There  has  been  slight  bleeding  lately, 
and  she  has  come  up  to  town  at  my  desire.  Dr.  Philson 
was  present.  I  found  a  growth  near  the  neck  of  the  bladder 
about  the  size  of  a  cherry,  which  I  removed  with  a  pair 
of  laterally  curved  forceps.  At  the  first  operation  I  had 
only  forceps  of  the  ordinary  form  used  in  lithotomy,  and 
could  not  command  any  outgrowth  thus  placed,  and  only 
constructed  other  forceps  as  fresh  circumstances  demanded. 
She  soon  returned  quite  well. 

1884,  J-pHi  17.  I  heard  there  was  no  frequency  of 
micturition,  and  that  there  was  no  pain.  Occasionally,  after 
exercise,  sees  a  few  drops  of  blood. 

Mr.  Stanley  Boyd  examined  the  parts  removed,  and 
reported  as  follows  : — '  The  growth  consisted  of  three  chief 
masses  of  roughly  spherical  form,  one-half  to  three-quarters 
of  an  inch  in  diameter,  and  having  short,  narrow  pedicles, 
and  of  two  or  three  small  sessile  masses  of  similar  shape. 
All  the  nodules  were  velvety  on  account  of  the  projection 


SOME    CASES    OF    OPERATION    IN    DETAIL  91 

everywhere  from  their  surfaces  of  thin  folds,  and  embranched, 
somewhat  club-shaped  processes,  one-sixteenth  of  an  inch 
or  less  in  length.  Under  the  microscope  these  processes 
consisted  almost  entirely  of  one  or  two  very  thin-walled 
vascular  loops  of  wide  calibre,  but  some  showed  a  good  deal 
of  round-celled  infiltration.  They  were  covered  by  a  thick 
layer  of  epithelium,  the  component  cells  of  which  were 
columnar,  very  long,  and  narrow  ;  the  epithelium  stripped 
off  with  the  greatest  ease.  The  mass  of  the  tumour  con- 
sisted of  rather  loose  connective  tissue,  containing  here  and 
there  small  collections  of  round  cells.  No  glandular  struc- 
ture was  seen.  Vessels  very  large,  numerous,  and  provided 
with  stout  coats  in  the  body  of  the  growth,  but  towards 
the  surface  large  numbers  of  the  same  wide,  thin-walled 
vessels  were  seen,  as  were  noticed  in  the  processes  on  the 
surface.  They  had  no  muscular  fibres  in  their  walls.  The 
surface  of  the  growth  between  the  processes  is  covered  by 
epithelium  similar  to  that  on  the  villi.  At  the  base  of  the 
nodule  examined  some  bundles  of  the  involuntary  muscular 
layer  of  the  bladder  were  seen,  but  no  such  tissue  existed  in 
the  growth.' 

Case  7. — W.  W.,  set.  63.     Fimbriated  papilloma. 

1883,  Jan.  24.  I  first  saw  him.  Occupied  on  the 
Thames  as  a  bargeman.  Seven  years  ago,  the  first  attack 
of  hsematuria  occurred  :  severe  ;  the  clots  causing  retention 
of  urine.  Several  attacks,  with  rather  long  intervals,  during 
the  succeeding  five  or  six  years. 

During  last  year  more  bleeding ;  during  last  month 
almost  continuously  seen.  All  this  time  he  has  worked 
hard  at  the  oar ;  he  bleeds  less  when  resting,  but  has  little 
pain  ;  holds  water  two  hours  or  more,  night  and  day.  Passes 
it  sometimes  quite  clear  at  beginning  of  stream,  ending 
deep  red. 

He  is  very  weak,  and  obviously  anaemic  from  loss  of  blood. 


92         ON  TUMOURS  OF  THE  BLADDER 

At  this  visit  he  passed  in  his  urine  a  shred,  which,  under 
the  microscope,  proved  to  be  a  perfect  specimen  of  fimbriated 
papilloma.     Hence  I  decided  at  once  to  operate. 

Feb.  8.  Dr.  Gfeorge  Johnson  and  others  present.  Found 
tumour :  rather  wide  base,  but  prominent ;  springing  from 
the  back  of  the  bladder  a  little  on  his  right  side.  I  nipped 
off  all  the  salient  portions,  leaving  a  slightly  projecting, 
ragged  base.  The  tube  was  introduced;  it  remained  five 
days. 

Feb.  20.  All  urine  still  by  wound;  generally  a  little 
blood  in  the  urine,  which  seemed  to  be  checked  by  mild 
daily  injections  of  perchloride  of  iron. 

March  2.  Up  and  going  about.  Very  little  bloodstain  ; 
urine  partly  passing  by  urethra. 

March  12.  No  blood  for  a  week ;  holds  urine  three 
hours.  Walked  an  hour  yesterday.  All  the  urine  by 
urethra. 

April  3.  Stronger  than  for  months ;  has  returned  to  his 
work. 

November  1.  Has  been  working  hard  all  summer  and 
autumn,  and  occasionally  sees  a  little  blood  when  work  is 
severe. 

1884,  April  16.  Called  on  me.  Continues  his  work. 
No  frequency  of  micturition  ;  no  pain ;  passed  a  little  urine 
with  faint  blood  tint. 

Dr.  Gribbes  examined  this  tumour,  and  reported  upon  it 
as  follows  :- — '  This  growth  consists  of  a  number  of  delicate 
filiform  processes :  each  of  these  consists  of  a  central  stalk 
from  which  branch  several  secondary  processes.  They  are 
formed  of  a  very  delicate  connective  tissue  in  the  centre, 
which  is  infiltrated  with  small  round  cells  ;  and  they  are 
covered  with  a  stratified  layer  of  columnar  epithelium,  which 
resembles  that  of  the  normal  bladder.  This  epithelium  is 
set  on  a  nucleated  basement  membrane;  a  large  blood-vessel 
enters  at  the  base  of  each  villus  and  branches  as  it  goes  on. 


SOME    CASES    OF    OPERATION    IN    DETAIL  93 

until  it  finally  breaks  up  into  a  network  of  capillaries,  which 
lie  directly  under  the  basement  membrane.  In  some  places 
these  capillaries  may  be  seen  to  have  ruptured  on  to  the 
external  surface.  The  whole  growth  is  very  vascular. 
Many  of  the  columnar  epithelial  cells  are  distended  with 
mucus.  In  some  of  the  processes  there  are  crypts  lined 
with  columnar  epithelium  similar  to  that  on  the  surface.' 

Case  10. — J.  S.,  set.  53.  Fibro -sarcoma,  or  transitional  (?). 

1881,  August  24.  I  first  saw  him.  Leading  an  active 
life ;  from  Wales.  Sent  to  me  by  Dr.  Maguire,  of  Holyhead. 
Last  six  months,  micturition  frequent,  little  painful  before 
and  after,  occasionally  slight  hsematuria.  Urine  healthy, 
no  organic  deposit  seen  ;  under  microscope  a  few  blood 
corpuscles. 

1882,  May  8.  He  came  up  again.  Slight  advance  in 
symptoms.  Sounded :  nothing  felt  worth  recording ;  pro- 
state rather  full ;  blood  little  increased. 

August,  Pain  increased  slightly ;  a  little  florid  blood 
lately  seen  at  the  close  of  micturition. 

November.  Pain  increases;  rarely  three  days  without 
marked  appearance  of  florid  blood ;  appetite  good ;  walks 
three  miles,  and  thinks  exercise  makes  little  or  no  difference. 
Nothing  characteristic  in  urine. 

1883,  March  2.  The  last  two  months  blood  has  appeared 
every  day,  and  passes  water  every  hour  day  and  night,  with 
much  local  pain  ;  none  in  legs  or  back. 

March  3.  Digital  exploration.  Mr.  Coward  and  others 
present.  Felt  a  large  mass  more  than  half  tilling  the  blad- 
der, and  much  harder  than  growths  usually  met  with.  Was 
compelled  to  use  the  forceps  with  cutting  edges,  removing 
great  part  of  it,  bit  by  bit,  with  great  care,  examining  afresh 
with  the  finger  after  every  portion.  Very  free  bleeding  for 
twenty-four  hours. 


94         ON  TUMOUES  OF  THE  BLADDER 

March  5.  Blood  diminishing.  Weak.  Abdominal  ten- 
derness. 

March  6.  Urine  passes  by  tube  freely ;  still  bloody. 

March  7.  Died  at  noon. 

March  8.  Autopsy  showed  a  portion  of  tumour  about 
base  remaining ;  of  very  firm  consistence,  and  apparently  con- 
tinuous with  the  coats  of  the  bladder.  Both  kidneys  small 
and  pale,  the  right  showing  marks  of  pyelitis. 

Mr.  Shattock  carefully  examined  the  bladder  with  a  view 
to  determine  the  connection  of  the  growth  with  the  organ, 
and  reports  as  follows : — '  A  vertical  section  carried  through 
the  middle  of  the  tumour  and  the  wall  of  the  bladder  shows 
the  morbid  growth  to  be  throughout  solid,  white,  of  soft 
consistence,  and  very  evidently  constructed  of  an  alveolar 
stroma,  from  which  the  contained  elements  can  be  expressed. 
The  growth  nowhere  extends  through  the  wall  of  the  blad- 
der ;  the  longitudinal  muscle-bundles  are  traceable  without 
interruption  beneath  its  base,  though  the  transverse  are 
unrecognisable  in  the  situation,  a  result  due  apparently  to  a 
displacement  rather  than  to  any  proper  disappearance  from 
infiltration  of  the  transverse  bundles  by  the  tumour. 

'  The  deep  limit  of  the  growth  is  clearly  defined,  convex, 
undulatory  or  lobular  in  character ;  the  tumour  substance 
has  nowhere  extended  laterally,  its  deep  limit  being  in  fact 
its  narrowest  part.  The  wall  of  the  bladder  beneath  the 
tumour  is  folded  inwards  for  a  depth  of  nearly  half  an  inch, 
a  condition  due,  doubtless,  to  the  enforced  dragging  of  the 
growth  upon  the  subjacent  part  of  the  bladder,  as  the  con- 
nective tissue  and  fat  lying  over  this  spot  are  quite  lax,  and 
present  no  induration  or  cicatricial-like  shrinking. 

'  A  microscopic  section  shows  throughout  an  alveolar 
stroma  of  connective  tissue,  the  wide  meshes  of  which  are 
filled  with  multiform  epithelial  cells,  many  of  an  elongated 
form,  columnar,  pyriform,  some  with  bifid  tails,  and  arranged 
with  the  long  axis  at  right  angles  to  the  wall  of  the  space 
which  holds  them. 


SOME    CASES    OF    OPERATION   IN   DETAIL  95 

'  Taking  all  the  facts  together,  there  is  no  evidence  that 
the  tumour  is  malignant.' 

Case  12.— C.  C.  S.,  ^t.  5Q.     'Transitional.' 

1883,  January  11.  I  first  saw  him.  Habits  sedentary. 
About  a  year  and  a  half  ago  severe  attack  of  painful  mictu- 
rition, followed  by  more  or  less  irritation  ever  since. 

Three  months  ago,  first  saw  blood  in  the  urine,  after  a 
long  walk.     Has  recurred  frequently  since. 

Now,  there  is  considerable  frequency  of  micturition,  pain, 
and  often  blood.  Sounded :  nothing  found ;  the  bladder 
empties  itself  by  its  own  efforts.  Kectal  examination  reveals 
nothing ;  in  the  urine,  no  signs  of  tumour  debris. 

He  returned  to  the  country  to  carry  out  some  treatment 
advised ;  but  his  symptoms  becoming  more  severe,  he  came 
to  town  again. 

April  3.  Sounded  and  otherwise  examined  under 
ether :  nothing  discovered ;  a  '  softish '  feel  in  rotating  the 
sound.  Tried  mild  injections  of  perchloride  of  iron.  He 
passed  some  small  phosphatic  concretions  a  week  or  two 
later.  As  he  made  no  progress,  I  decided  to  explore  with  the 
finger. 

May  4.  The  brother  Dr.  S.,  and  others  present.  I  found 
a  broad  sessile  tumour  occupying  (his)  right  side  of  bladder ; 
one  which  it  was  clearly  impossible  to  remove,  since  its 
incorporation  with  the  walls  of  the  bladder  was  manifest.  I 
nipped  off  two  of  the  most  salient  portions  of  the  mass, 
diminishing  it  considerably,  and  put  in  the  tube.  It  re- 
mained two  days,  when  all  bleeding  ceased.  He  left  for  the 
country,  the  wound  being  healed  and  symptoms  relieved,  on 
May  24. 

1884,  May  10.  Came  up  again  to  see  me,  with  much 
frequency  and  pain,  but  with  little  bleeding ;  troubles 
mainly  due  to  some  phosphatic  deposits,  which  were  re- 
moved by  lithotrite  and  aspirator  under  ether ;  and  he  left 
again,  relieved,  but  suffering  much  at  times,  on  May  20. 


96         ON  TUMOURS  or  THE  BLADDER 

Dr.  Gibbes  examined  this  tumour,  and  reported  upon  it 
as  follows : — '  This  tumour  appears  to  be  an  hypertrophy  of 
the  submucous  coat  of  the  bladder.  The  muscle  appears 
normal,  but  the  tissue  inside  it  is  composed  of  dense 
bands  of  fibrous  tissue,  which  are  irregular  in  direction,  and 
which  have  here  a  macerated  or  sodden  appearance,  as  if 
there  had  been  great  oedema  into  them.  Nearer  to  the 
epithelium  the  fibrous  tissue  is  much  finer,  and  directly 
under  the  epithelium  it  has  a  reticulated  appearance, 
exactly  resembling  granulation-tissue  in  the  bottom  of  a 
healing  wound.  The  epithelium  on  the  surface  resembles 
that  of  the  normal  bladder  in  every  respect.  The  blood- 
vessels in  the  depths  have  very  thick  walls,  and  are  sur- 
rounded with  round  cells  in  some  places.  The  capillaries 
run  directly  to  the  surface,  generally  without  branching,  and 
are  there  ruptured  in  many  places.  They  are  also  ruptured 
in  some  parts  of  the  deeper  tissue,  and  there  are  many  spots 
of  extravasated  blood.  There  are  collections  of  round  cells, 
and  numerous  irregularly  shaped  large  cells,  in  some  places 
resembling  "  lymphoid "  tissue,  and  these  are  arranged  in 
round  or  oval  masses. 

'  There  are  no  papillomatous  or  "  villous  "  growths  in  that 
portion  of  the  tumour  examined.' 

The  microscopic  drawing,  Plate  V.,  was  taken  from  the 
above  described  tumour. 


TABLE   OF  CASES  OF  OPERATION  FOR 
VESICAL   TUMOUR. 


II 


98 


TABLE    OF    CASES. 


TABLE    OF   TWENTY  GASES    OF   OPERATION   FO 


Date  of 
operation 


1880, 
Nov.  6 


T.K. 


29 


1882, 
May  9 


Mrs.  F. 


30 


Nov.  3 


B.  G. 


Turation  of 
symptoms 


Earliest  sign 
observed 


Besult  of  urine 
examination 


3^years 


Blood  in  the  urine 


46     1      year 


Not  examined,  no 
growth  being  ex- 
pected; the  opera- 
tion was  made  for 
a  supposed  encysted 
calculus 


Ditto 


Frequent  micturi- 
tion; blood  much 
later 


Much  large  cell- 
growth  ;  various 
forms 


Complicatioi 
with  calculu 


A  small  oxf 
late  of  lim 
and  pho; 
phatic  ca 
cuius 
crushed 


1 


TABLE    OF    CASES. 


99 


^SIGAL   TUMOUR  BY  SIR  HENRY  THOMPSON. 


Nature  of  tumour 


|bro-papilloma 


ibro  -  papilloma : 
with  '  club-shap- 
ed processes,'  not 
slender  papillae 
or 'villi'  (Mr.  S. 
Boyd) 


Perhaps  interme- 
diate between 
papilloma  and 
sarcoma.'  Proba- 
bly belonging  to 
the  group  termed 
below  '  transi- 
tional' (Mr.  S. 
Boyd) 


Operation  and  result 


Single  polypoid  growth;  removed  at 
base  by  forceps.  Dr.  Paggi,  of  Flo- 
rence, Dr.  Seegen,  of  Carlsbad,  and 
Mr.  Ceeley,  of  Aylesbury,  present. 
Rapid  recovery.  Living  and  well,  spring 
1884 


Polypoid  growths  ;  removed  by  forceps  ; 
recovery  rapid.  Seen  with  Dr.  Philson, 
of  Cheltenham.  February,  1883.  Re- 
moved a  small  growth  which  I  had 
been  unable  to  grasp  at  first  opera- 
tion for  want  of  forceps  acting  late- 
rally ;  she  was  well  in  a  few  days 
and  returned.  1884,  April  17 :  heard 
that  she  is  quite  well ;  there  is  no 
frequeocy  of  passing  water  ;  no  pain  ; 
after  exercise  a  i  race  of  blood  is  some- 
times seen 


Very  large  ;  almost  entirely  removed  by 
forceps ;  great  hsemorrhage  ;  died  few 
days  after  operation ;  no  autopsy  per 
mitted  ;  probably  some  giving  way  of 
bladder  at  base  of  tumour 


H  -2 


100  TABLE    or    CASES. 

TABLE  OF  TWENTY  GASES  OF  OPERATION  FO 


Date  of 
operation 

1882, 
Nov.  20 


No. 


Case 


Dr.  M. 


52 


1883, 
Jan. 17 


E.  K.  G. 


67 


30 


T.  F. 


67 


Duration  of 
symptoms 


5    years 


Ear'iiest  sign 
observed 


Blood  in  the  urine 


Eesult  of  urine 
examination 


Shreds  formed  of  fusi- 
form cells 


Ditto 


Nuroei*ous      fusiform 
cells  and  fibres 


Complication 
with  calculus 


A  small  uri( 
acid  calcu 
lus  crushec 


TABLE    OF    CASES. 


101 


\ESIGAL   TUMOUR   BY  SIR  HENRY  THOMPSON  (continued). 


Nature  of  tumour 


Operation  and  result 


■  Diagram  of 
form  and  situation  of  tumour 


he  base  of  the 
growth  contains 
unstriped  muscu- 
lar fibres  not  con- 
tinued into  the 
filiform  processes, 
which  arise  in 
great  number, 
and  form  long 
villi.  Normal 

bladder  tissue 
with  fimbriated 
papillae  (Dr.  H. 
Gibbes) 


apilloma ;  resem- 
bling structure  of 
'  soft  warts  '  (Mr. 
Shattock) 


Spithelioma 
H.  Gibbes) 


(Dr. 


Rather  broad-based  growth,  springing 
from  side  of  the  bladder.  Seen  with 
Dr.  Geo.  Johnson.  The  patient  was 
free  from  bleeding  for  nearly  six 
months  after  operation ;  then  little 
blood  seen  after  a  seven  miles'  walk, 
and  continued.  In  June,  1883, 1  made 
a  slight  exploration  and  removal,  fol- 
lowed by  relief.  On  February  10, 1884, 
I  again  explored,  and  removed  a 
larger  quantity  than  on  either  pre- 
vious occasion ;  the  bleeding  had 
been  very  severe  during  the  preceding 
two  months.  He  made  a  slow  recovery, 
being  much  exhausted  prior  to  the 
last  operation 


Sessile,  and  partially  removed.  Returned 
to  Cape  ;  probable  reappearance  of  the 
tumour.  Heard  of  his  death  there 
subsequently 


Broad  and  sessile ;  removed  much  of 
it.  Signs  of  reappearance  of  tumour 
in  the  spring ;  and  in  the  summer  he 
died 


102  TABLE    OF    CASES, 

TABLE  OF  TWENTY  GASES  OF  OPERATION  FOl\ 


No. 


Age 


Duration  of 
symptoms 


w.  w. 


63 


J.  M. 


64 


Mrs.  O'E. 


65 


7  years 


1  year 


7  years 


Earliest  sign 
observed 


Blood  in  the  urine 


Eesult  of  urine 
examination 


Well-marked    villous 
growth 


Complication 
with  calculus 


Never  found  any  cha- 
racteristic debris  in 
uiine 


Large  spindle-shaped 
cells ' 


Calculus  in 
left  kidney, 
large ;  both 
kidnej's  dis- 
eased ;  pye- 
litis 


TABLE    OF    CASES.  103 

VESICAL   TUMOUR  BY  SIR  HENRY  THOMPSON  {continued). 


Nature  of  tumour 


Operation  and  result 


Diagram  of 
form  and  situation  of  tumour 


'imbriated  papil- 
loma chiefly ; 
very  vascular  (Dr. 
H.  Gibbes) 


Composed  of  nor- 
mal bladder  tissue; 
fimbriated  pa- 
pilla ('  villi  ') 
abundant  :  no 
structure  resem- 
bling malignant 
growth  was  found 
(Dr.  H.  Gibbes) 


Papilloma 
Eve) 


(Mr. 


Rather  broad-based  polypoid  growth  ; 
freely  removed.  He  was  so  weak  with 
long-continued  haemorrhage,  I  almost 
feared  to  operate.  Living  and  well 
in  the  spring  of  1884,  working  as  a 
bargeman  on  the  Thames.  Seen  with 
Dr.  Geo.  Johnson 


Broad  and  sessile ;  removed  rather 
freely.  Died  two  months  after  with 
secondary  malignant  growth  in  thigh. 
Seen  with  Dr.  Harvey,  of  Bayswater 


Large  tumour,  freely  removed,  leaving 
the  base,  which  was  broad.  Died 
three  days  after  with  suppression  of 
urine.  Seen  with  Mr.  Thurland,  of  Wil- 
mington Square,  with  whom  autopsy 
was  made.  Kidneys  much  diseased; 
large  calculus  in  the  left 


104 


TABLE    OF    CASES. 


TABLE  OF 

TWENTY  CASES  OF  0PEEA2 

'ION  FO 

Date  of 

No. 

Case 

Duration  of 

Earliest  sign 

Result  of  urine 

Complication 

operation 

Age 

■  symptoms 

observed 

examination 

with  calculus 

1883, 

10 

J.  H. 

53 

2^    years 

Frequent  and  pain- 

No characteristic  de- 



Mar.  3 

ful      micturition. 

bris  found 

Blood     at      later 

" 

stage 

„30 

11 

W.  D. 

65 

1     year 

Blood  later 

Numerous  long  cells 
and  fibres 

■—      - 

May  4 

12 

c.  c.  s. 

56 

2  years 

Pain     first ;     blood 
later 

Nothing  found 

— 

TABLE    OF    CASES. 


105 


VESICAL   TUMOUR  BY  SIR  HENRY  THOMPSON  {continued). 


Nature  of  tumour 


Operation  and  result 


Diagram  of 
form  and  situation  of  tumour 


Tissues  like  those 
forming  the  wall 
of  the  bladder, 
with  fimbriated 
papillae  (Mr. 

Shattock) 


Tissues  like  those 
of  the  walls  of 
the  bladder,  and 
some  papilliform 
growth  in  small 
quantity  on  sur- 
face (Dr.  H. 
Gibbes) 
Fibro-papilloma 


Example  of  growth 
termed  '  transi- 
tional.'  The 
structure  resem- 
bles a  '  hyper- 
trophy of  the  sub- 
mucous coat  of 
the  bladder ;  col- 
lections of  round 
cells  in  some 
places  resembling 
lymphoid  tissue ; 
no  papillomatous 
growth  present ' 
(Dr.  H.  Gibbes) 


Large  hard  tumour  partially  removed  ; 
largely  involving  the  coats  of  the 
bladder.  Died  few  days  after  operation. 
Sent  to  me  by  Dr.  Maguire,  of  Holyhead 


Sessile ;  firm ;  removed  salient  por- 
tions. Died  fourteen  days  after  opera- 
tion, of  exhaustion.  Seen  with  Mr. 
T.  W.  Mason,  of  Regent's  Park 


Tumour  firm,  sessile  ;  inseparable  from 
walls  of  bladder;  removed  salient 
portions  only.  Living ;  symptoms  re- 
lieved at  present ;  probably  from 
drainage  of  bladder.  1884,  May  10: 
came  to  see  me ;  washed  out  many  small 
phosphatic  concretions  wiih  great 
relief.  Tumour  not  much  increased  ; 
occasiorally  some  blood  in  urine ;  on 
the  whole  the  symptoms  not  worse 


106 


TABLE    OF    CASES. 


TABLE  OF 

TWENTY  CASES  OF  OPERATION  FO.^ 

Date  of 
operation 

No. 
13 

Case 

Age 

Duration  of 
symptoms 

Earliest  sign 
observed 

Besult  of  urine 
examination 

Complication 
with  calculuB 

1883, 
May  9 

T.  Q. 

52 

4     years 

Frequent    micturi- 
tion     and     pain. 
Blood    seen     two 

Passed  mass,  the  size 
of  large  pea,  of  soft 
fleshy     material    in 

None 

years  ago 

urine ;     when     exa- 
mined   by    Dr.     II. 
Gibbes  appeared   to 
be  portion  of  growth, 
composed  of  normal 
vesical  elements 

June  27 

14 

A.G.S.C. 

57 

)>        »» 

Frequent     micturi- 
tion :  soon  after  an 
attack  of  bleeding 

No  cells  of  suspicious 
appearance  found  in 
the  urine 

— 

July  7 

15 

J.  H.  B. 

40 

3        „ 

Blood  seen  at  the 
first ;    now    daily 
and  profuse  bleed- 
ing.     Micturition 
never     very    fre- 
quent 

No  Evidence  obtained 
from  the  urine 

-    — 

TABLE    OF   CASES. 


107 


VESICAL   TUMOUR  B      SfE  HENRY  THOMPSON  {contvnued). 


Nature  of  tumour 


Made  up  of  un- 
striped  muscular 
fibres,  with  nume- 
rous tubes  and 
crypts  lined  with 
columnar  epithe- 
lium ;  probably 
malignant  (Dr.  H. 
Gibbes) 


Made  up  of  un» 
striped  muscular 
fibres ;  numerous 
small  cells  inter- 
spersed; nume- 
rous fimbriated 
papillfB  (Dr,  H. 
Gibbes) 


The  body  of  the 
tumour  made  up 
of  normal  ele- 
ments of  the  vesi- 
cal walls  with 
here  and  there  in- 
filtration of  small 
round  cells.  Abun- 
dant fimbriated 
processes,  'vil- 
lous '  from  every 
part 


Operation  and  result 


A  soft  growth,  removed  to  the  base. 
Much  bleeding  up  to  second  day ;  be- 
came feverish,  indisposed  to  take 
food,  and  gradually  sank  on  the  twelfth 
day.  Mr.  W.  Adams,  of  Regent's  Park, 
was  present  at  the  operation 


Diagram  of 
form  and  situation  of  tumour 


Sessile  growth,  implicating  the  walls  of 
the  bladder,  and  could  only  be  par- 
tially removed.  Rapid  recover^'.  Dr. 
Weir,  of  New  York,  was  present.  Had 
no  bleeding  for  two  months  after 
operation.  April  17  :  micturition  fre- 
quent and  painful ;  much  blood  at 
times ;  the  growth  evidently  increasing 


A  rather  large  polypoid  growth  removed 
entire  at  once.  Recovery  rapid.  An 
assistant  to  Dr.  Bell,  of  Rochester. 
Professor  Holmer,  of  Copenhagen,  pre- 
sent. He  was  so  reduced  by  persistent 
hemorrhage,  that  I  operated  with 
great  reluctance.  1 884,  April  20  :  he 
writes  that  he  is  actively  employed, 
but  has  seen  after  exercise  '  occa- 
sionally a  few  drops  of  blood,  just  as 
he  did  three  or  four  years  ago ; ' 
'  health  good  ' 


108 


TABLE    OF    CASES. 


TABLE  OF  TWENTY  GASES  OF  OPERATION  FOR 


Date  of 
operation 

1883, 
Nov.  16 


Case 


Age 


16 


T.  S. 


42 


1884, 
Feb.  5 


17 


D.  of  B. 


50 


Mar.  12 


18 


W.  G. 


69 


Duration  of 
symptoms 


Earliest  sign 


8     years 


nearly  4 
years 


Attacks  of  has  mat- 
uria;  of  late  mic- 
turition frequent 


Attacks  of  frequent 
and  painful  mic- 
turition,with  little 
blood 


Blood  occasionally 
seen  eight  or  ten 
years  ago ;  last 
four  years  very 
often ;  frequent 
micturition  only 
recently 


Besult  of  urine 
examination 


Shreds  of  tissue 
passed,  made  up  of 
spindle-shaped  cells 
and  fibres  with  nu- 
clei on  them 


Shreds  of  tissue 
washed  out  show 
villous  structure 


Shreds  of  tissue 
washed  out  show 
numerous  large  nu- 
cleated spindle- 
shaped  cells 


Complication 
with  calculus 


TABLE    or    CASES. 


109 


VESICAL   TUMOUR  BY  SIR  HENRY   THOMPSON  (continued). 


Nature  of  tumour 


Operation  and  result 


Diagram  of 
form  and  situation  of  tnmour 


Normal  structure 
of  bladder  co- 
vered with  fim- 
briated papillee ; 
but  groups  of 
small  cells  are 
seen  in  places  in 
the  substance  of 
the  papillae  (Dr. 
H.  Gibbes) 


Growth  like  a  cauliflower,  from  rather  i 
wide  base  ;  removed  all  but  the  latter ;  I 
A  good  recovery.  Seen  with  Mr.  "Wood-  j 
cock,  of  Knutsford,  Cheshire,  who  was 
present  at  the  operation.     1 884,  ilav 
10  :  called  on  me.     He  attends  to  the 
active  duties  of  his  profession  as  land- , 
surveyor,  but  after  more  exercise  than 
usual  sees  a  little  hgemorrhage.     Has 
been   busily  occupied   some  days  in  \ 
London  and  seen  no  blood :   no  fre- ! 
quency  or  pain  in  micturition  [ 


Normal     structure  A  firm   broad-based   growth  from  the 

of  bladder,   with  back  of   the  bladder :   from  which   I 

numerous      large  removed  the  salient  portions ;  and  it 

papillae,         from ;  appeared  to   me   that   a    suprapubic 

which  spring  the  |  operation  would    not   enable   me    to 

long     fimbriated :  remove  the  tumour  entire.     June  3 : 

processes            in  '  symptoms  now  very  slight ;  no  pain : 

abundance ;  a  few  walks    three    miles    without    seeing 

leucocytes      seen  blood 
(Dr.  H.  Gibbes)     ; 


Normal  structure 
of  bladderchiefly ; 
no  long  papillae 
or  '  villi,'  but 
broad  papUls  co- 
vered with  strati- 
fied columnar  epi 
thelium  (Dr.  H. 
Gibbes) 
Fibro  -papilloma 


A  broad-based  sessile  mass,  of  firm  con-  [ 
sistence,  involving  the   coats   of  the 
bladder ;  it  would  be   useless,  there- 1 

;     fore,  to  propose  suprapubic  operation. 

,     Eemoved  two  or  three  salient  portions.  | 
He  gradually  sank,  about  three  weeks  i 
afterwards.   Seen  with  Dr.  Geo.  .John- 
son, who  was  present  at  the  operation 


110 


TABLE    OF    CASES. 


TABLE  OF  TWENTY  CASES  OF  OPERATION  FOl 


Date  of 
operation 

1884, 
April  4 


No. 


19 


Age 


F.  J.  0. 


58 


May  30 


20 


R.  S.  R. 


63 


Duration  of 
symptoms 


9  months 


15 


Earliest  sign 
observed 


Severe 
first 


bleeding 


Result  of  urine 
examination 


Complication 
•n-ith  calculus 


Nothing  found  in  the 


Bleeding  after  ex- 
ercise was  the  first 


/ 


Fragments  removed 
from  the  bladder  bj^ 
the  aspirator,  no- 
thing being  found 
in  the  urinary  de- 
posit by  simply 
washing  out 


TABLE    or    CASES. 


Ill 


VESICAL   TUMOUR  BY  SIR  HENRY  THOMPSON  (continued). 


Nature  of  tumour 


Operation  and  result 


Diagram  of 
form  and  situation  of  tumour 


Normal  structure 
of  bladder  chiefly; 
groups  of  small 
round  cells ;  some 
like  inflammatory 
cells :  resembling 
Cases  12,  li,  and 
16 :  and  regarded 
as  '  transitional.' 
No  long  papillae 
(Dr.  H.  Gibbes) 


Normal  structure  of 
bladder,  covered 
with  columnar 
epithelium  ;  un- 
der latter,  round 
cells  Uke  '  lym- 
phoid tissue  ; ' 
somewhat  uncer- 
tain (Dr.  H. 
Gibbes) 


A  firm  broad  sessile  tumour,  with  very 
slight  lobulation ;  could  not  be 
separated  from  walls  of  the  bladder. 
Removed  a  small  portion  for  examina- 
tion. Wound  soon  healed.  Seen 
with  Dr.  Dove,  of  Pinner 


A  firm  multilobular  tumour,  with  broad 
peduncle,  which  was  removed  almost 
level  with  the  walls  of  the  bladder. 
Dr.  Shippen,  of  New  York,  and  Dr. 
Charamis,  from  Paris,  present.  Re- 
covering rapidly.     June  7,  1 88-i 


LOJTDON  :     PDINTEn     I!V 

SPOTTISWOODE    AXD     CO.,    XEW  STREET     SQUAUK 

ASD     PAEI.I.\iIE5T   STREET 


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